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CIHM 

ICMH 

Microfiche 

Collection  de 

1 

Series 

microfiches 

1- 

(Monographs) 

(monographies) 

vV 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


99 


Technical  and  Bibliographic  Notes  /  Notej  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming    Features  of  this  copy  which 
may  be  bibliographically  unique,  which  may  alter  any 
of  the  images  in  the  repioduction,  or  which  may 
significantly  change  the  usual  method  of  filming,  are 
checked  below. 


D 
D 
D 
D 
D 
D 


Coloured  covers/ 
Couverture  de  couleur 

Covers  damaged/ 
Couverture  endommagee 

Covers  restored  and/or  laminated/ 
Couverture  restauree  et/ou  pellicul6e 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 


0  Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 


D 


Bound  with  other  material/ 
Relie  avec  d'autres  documents 


I — ^  Tight  binding  may  cause  shadows  or  distortion 

I  ^  I  along  interior  margin/ 

La  ret  ure  terr^  peut  causer  de  rombre  ou  de  la 
distorsion  le  long  de  la  marpe  interieure 


D 


Blank  leaves  added  during  restoration  may  appear 
within  the  text.  Whenever  possible,  these  have 
been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajouties 
lors  d'une  restauration  apparaissent  dans  le  textu, 
mais,  lorsque  cela  itait  possible,  ces  pages  n'ont 
pi:%  ixi  filmies. 


L'lnstilut  a  microfilm^  le  meilleur  exemplaire  qu'il 
lui  a  itk  possible  de  se  procurer.   Le>  details  de  cet 
exemplaire  qui  sont  peut-itre  uniques  du  point  de  vuc 
bibliographique,  qui  peuvent  modifier  une  image 
reproduite,  ou  qui  peuvent  exiger  une  modification 
dans  la  m6thode  normale  de  f  ilmage  sont  indiques 
ci-dessous. 

0  Coloured  pages/ 
Pages  de  couleur 

□  Pages  damaged/ 
Pages  endommag^s 

□  Pages  restored  and/or  laminated/ 
Pages  restauries  et/ou  pellicultes 

I        I  Pages  discoloured,  stained  or  foxed/ 
I        I  Pages  decolor^j,  tachetees  ou  pquees 


0 


Pages  detached/ 
Pages  detachees 


0Showthro(<gh/ 
Transparence 


0 

D 
D 


Quality  of  print  varies/ 
Qudlite  inigale  de  I'impression 

Continuous  pagination/ 
Pagination  continue 

Includes  index(es)/ 
Comprend  un  (des)  index 

Title  on  header  taken  from:/ 
Le  titre  de  i'en-t£te  provient: 


The 
to  t 


The 
pos: 
oft 
film 


Orifl 

begi 

the 

sion 

oth< 

first 

sion 

or  il 


The 
shall 
TINl 
whi( 

Map 
diffa 
entir 
bagii 
right 
requ 
matt 


□  Title  page  of  issue/ 
Page  de  titre  de  la  livraison 

□  Caption  of  issue/ 
Titre  de  depart  de  la 


D 


depart  de  la  livraison 

Masthead/ 

Generique  (periodiques)  de  la  livraison 


\/ 


Additional  ccmmentj:/ 
Commentaires ; upplcmentaires: 


Various  pagings.        Copy  has  manuscript  annotataions.  Some  pages  are  cut  off. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Co  document  est  f  ilme  au  taux  de  rMuction  indiqui  ci-dessous. 

10X  14X  18X 


22X 


26X 


30X 


J 

12X 


16X 


20X 


24  X 


28X 


32  X 


The  copy  filmed  hare  has  been  reproduced  thanks 
to  the  generosity  of: 

Osier  Library, 
McGill  University, 
Montreal 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  p^ge  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  ov  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  -^^  (moaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc..  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirniy  included  in  one  exposure  are  filmed 
begiHning  in  the  urjper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


L'exemplaire  filmi  fut  reproduit  grdce  it  la 
gAnArosit6  de: 

Osier  Library, 
McGill  University, 
Montreal 

Les  images  suivantes  ont  M  reproduites  avec  le 
plus  grand  soin.  compte  tenu  de  la  condition  at 
de  la  nenet*  de  l'exemplaire  film*,  et  en 
conformity  avec  las  conditions  du  contrat  de 
filmage. 

Les  exempleirea  originaux  dont  la  couverture  en 
pepier  eat  imprim«e  sont  filmis  en  commsnqant 
par  la  premier  plat  et  en  terminant  soit  par  la 
derniAre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmAs  en  commenpant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniire  page  qui  comporte  une  telle 
empreinte. 

Un  dee  symboles  suivants  apparaitra  sur  la 
derniire  image  de  cheque  microfiche,  selon  le 
ce-^:  le  symbole  — ^  signifie  "A  SUIVRE ',  le 
symbols  V  signifie  "FIN". 

Les  cartas,  planches,  tableaux,  etc.,  peuvent  dtre 
fiimis  A  des  taux  de  reduction  diffdrents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
reproduit  en  un  seul  cliche,  il  est  film^  A  partir 
de  Tangle  supArisur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'im&ges  n^cessaire.  Les  diagrammes  suivants 
illustrent  la  mithode. 


1 

2 

3 

4 

5 

6 

COLLECTED  REPRINTS. 


THIRD  SERIES. 


(January  1st,  1892-January  1st,  1897.) 


WILLIAM  OSLER,  M.  D.,  F.  k.  c  p.,  Lox,,., 

Professor  of  Medicine  i.  (he  Johns  IIopLi.s  Unirersity,  „ud  Physician-in. Chief 
to  the  Johns  Hopkins  ITospilal,  Ballbnore. 


TITLES   OF    PAPERS. 

{Continued  from  Series  II.) 


CXVIII, 
CXIX. 

cxx. 


cxxi: 

CXXII. 

CXXIII. 

CXXIV. 

CXXV. 

^CXXVI 

CXXVII. 


Remarks  on  Specialism. 

£osto7i  Medical  and  Surgical  Journal,  1892 
The  healing  of  Tuberculosis. 

^^e  Climatologiat,  1892. 
Un  the  Association  of  Congenital  Wry-Neck  with 
marked  Facial  Asymetry. 

Archives  of  Pediatrics,  1892 
Interstitial  Processes  in  the  Central  Nervous  Sys-' 
tem.  ^ 

Transaction,  of  the  Congress  of  American  Phy- 
sicians  and  Surgeons,  1892. 
The  Cold  Bath  Treatment  of  Typhoid  Fever. 

Medical  News,  1892. 
Teacher  and  Student.     (An  Address.) 

m  ,        ,       „  Baltimore,  1892. 

luberculous  Pericarditis. 

American  Journal  of  the  Medical  Sciences,  1893 
On  Dilatation  of  the  Colon  in  Young  Children. 
^  Archives  of  Pediatrics,  1893 

f  hysic  and  Physician  as  depicted  in  Plato. 

Boston  Medical  and  Surgical  Journal,  1893 
Arteno- Venous  Aneurism  of  the  Axillary  Artery 
and  Vein  of  Fourteen  Years  Duration. 

Annals  of  Surgery,  1893. 
3 


CXXVIII.   The  ClirdPic  Intermittent  Fever  of  Endocarditis. 

The  Practitioner,  1893. 
CXXIX.   On  tlio  Varieties  of  Chronic  Chorea. 

Joiiniaf  of  Nervous  and  Mental  Diseases,  1893. 
CXXX.   On  Arsenical  Neuritis. 

Montreal  Medical  Journal,  1 893. 
CXXXI.   On  n  I^eninrknhie  Honse  Epidemic  of  Typhoid 
Fever.        University  Medical  Magazine,  1893, 
CXXXII.   Cases  of  t5ul)-rhrenic  Abscess. 

Canadian  Practitioner,  1893, 
CXXXIII.   Tuhcroiilous  Pleurisy  (Shattuck  Lecture). 

Tranx'u'tion.1  of  (he  Massachusetts  Medical  Society,  1893. 
CXXXI V.   American   Text-Book   of  Diseases   of  Children; 

Article  on  Tuberculosis,  1893. 
CXXX^'.   American   Te.\t-Book   of  Medicine;  Articles  on 
Diseases  of  the  Nervous  System  and  Blood- 
Olantlular  System,  189.3. 
CXXXV'I.   On  SjHJradic  Cretinism  in  America. 

Amvrican  Journal  of  Medical  Sciences,  1893. 
CXXX\'ir.   Notes  on  Tuberculosis  in  Children. 

Archives  of  Pediatrics,  1893. 
CXXX\'JII.   Toxaenn'a  in  Tuberculosis. 

The  Practitioner,  1893. 
CXXXIX.   Parotitis  in  Pneumonia,  and  Pericarditis  treated 
by  Incision. 

University  Medical  Magazine,  1894, 
CXL.   Aiuilysis  of  229  Cases  of  Typhoid  Fever. 

Johns  Jlopkins  Hospital  Reports,  Vol.  IV,  1894. 
CXLI.   Treatment  of  Typhoid  Fever.  Ibid.,  1894. 

CXLII.  Study  of  tiie  Fatal  Cases.  Jbid.,  1894. 

CXLIII.  Special  Symptoms,  Complications  and  Sequelae. 

Ibid.,  1894. 

CXLIV.   On  the  Neurosis  following  Enteric  Fever,  known 

aa  "  The  Typhoid  Spine."  /6trf.,  1894, 

CXLV.  Typhoid  Fevor  in  Baltimore,  Ibid.,  1894. 


CXLVI.   Lectures  on  the  Diagnosis  of  Abd. 
Nexv  York  Medical  Journal,  1894 


lominal  Tiimom 
lieprinted 


CXLVII 
CXLVIII. 
CXLIX. 
CL 
CLI. 
CLII. 
CLIII 


Book  For,n,  Appkton  &  Co.,  New  York 


m 


The  Army  Surgeon.     (An  Add 


1894. 


ress.) 


Medical  News,  1894. 


CLIV, 
CLV, 

CLVI. 

CLVII. 

CLVIII. 

CLIX. 
CLX. 

CLXI. 
CLXII. 


The  Leaven  of  Science.     (An  Address.) 

University  Medical  Magazine,  1894 
On  Chorea   and  Choreifbnu  Affections.     (Mono- 

graph.)  T      , 

nr       „.  London,  1894. 

Oliver  Wendell  Holmes. 

Johns  Hopkins  Hospital  Bulletin,  1894 
t^Jinical  Demonstrations  on  Typhoid  Fever. 

Maryland  Medical  Journal,  1894 

Cancer  ofStomach  with  very  Rapid  Course. 

•  University  Mediml  Magazine,  1894. 
leach.ng  and  Thinking.     (An  Address.) 

Qn       r    r,  ^'''"^'"''''^  Medical  Journal,  m5 

Sporad.  Cretinism.      Arck^,,  of  PediaVri^^,  1895 

Typho.d  Fever  in  Country  Districts. 

Maryland  Medical  Journal,  1895 
Visible  Contractile  Tumor  at  the  Pylorus. 

Montreal  Medical  Journal,    .-95 

American  Text-Book  of  Nervous  Diseases;  Artu.^.' 
on  Infective  Diseases,  1895. 

Five  Years  Experience  with  the  Cohl  Bath  Treat- 
ment of  Typhoid  Fever. 
Johns  Hopkins  Hospital  Reports,  Vol.  V,  1895 
Studies  in  Typhoid  Fever.  n^^^^,,,^^ 

J>feunti8  during  and  after  Typhoid  Fever. 

Pkiii    •    rn     ,  ^bid.,  1895, 

Chills  m  Typhoid  Fever.  j,,^^,^^^ 

Practical  Value  of  Laveran's  Discoveries. 

Medical  News,  1895. 


n  ii 


6 


CLXIII 


CLXIV. 

CLXV. 

CLXVI. 

CLXVII. 

CLXVIII. 
CLXIX. 

CLXX. 

CLXXI. 

^      CLXX  II. 
CLXXIII. 


Visceral  Cmplications  of  Erythema  Exu.Iativum 
Multiforme. 

American  Journal  of  Medical  Sciences,  1895. 
John  Keats 

Johns  Hopkins  Hospital  Bulletin,  1896 
Thomas  Dover.  y^  ■,;  _  j^y^. 

An  Alabama  Student.  ni,i_^  j^gy^ 

Six  Cases  of  Addison's  Disease. 

International  Medical  Magazine,  1896. 

Addison's  Diseiuse.  Medical  Bulletin,  1896. 

Heart  Hypertrophy  with  Adherent  Pericardium. 

Archives  of  Pediatrics,  1896. 

Hemiplegia  in  Typhoid  Fever. 

Journal  of  Nervous  and  Mental  Diseases,  1896. 
Treatment  of  Diseases  of  the  Blood  and  Ductless 
Glands. 

Handbook  of  Applied  Therapeutics,  1896. 
Cerebral  Complications  of  Raynaud's  Disease. 

American  Journal  of  Medical  Sciences,  1896. 
Lectures  on  Angina  Pectoris  and  Allied  States. 

New  York  Medical  Journal,  1896. 


^  >>  VIM 


-ythenia  Exudativum 

'edical  Sciences,  1895. 

ipUat  Bulletin,  1896. 
/6m/.,  189(5. 
Ibid.,  189G. 

ical  Magazine,  1896. 

i/ca/  Bulletin,  1896. 

lerent  Pericardium. 

of  Pediatrics,  1896. 

n<a/  Diseases,  1896. 
flood  and  Ductless 

Therapeutics,  1896. 
laud's  Disease. 
ical  Sciences,  1896. 
d  Allied  States, 
'ca/  Journal,  1896. 


fiMRKS  ON  SPECIALISM. 


BV 


'""""""■•'  O'  M.DICINB 


WILLIAM   OSLER,   M,  O 


'"  ^"'  •'°""''  H°"c.Ns  Un,v„,, 


""■v.  Baltimore. 


a 


I 


••  J.  PARKHILL  4  CO.,  | 
■OtTON 


RKMAUKS  ONSFKCIALlSMi 

I'!'"'  ti.is  chair.  '  1  v"  I^uJT  '"'"""''^'^  '"•'^"- 
ollioor  „no  whose  Lllu  "T  }  ""  >""'"  {"•t'«i<lini' 
general  n.ed  ci,^   ,•«"'';,  ?^,    '•""   V'  "'"  "'''«  "el-l  o^f 

n>e,lidne,  a,  ^eU::7^I^/T:;'r^    ""' h''"''' 

M'Tice  to^haracterL  us  rr.     ;  r''"'  T"'  ^"^«*-'"» 
yet  been  sta.nr.e.i  wiS.  «',  .  "^  ^  '^"^  '"'^«  "»'  «« 

which  80  „,a„v  o    m     00   r       "'  '^'T"'*"""'  ""'>«'• 
I"  theextraonilr'  l"'''"''""''*  '"«'''«'•  ''"es  hibor. 

limitation        vorH^-^n         ?^  '"°'^«'-"  '"^''i^i'H^ 

of  a  very  uatural  del«  /'        •    «;g'»"ze(l  expression 
.study.    ^  "^'""*'  '"  ""'^'^  f""-  tl'e  purposes  of 

On  an  occasion  of  this   Win/i  :*  . 
"ot  to  discuss  an  J  nL-     1  ,  ^  ^®^"*   ''^s'  'o  me 


/i- 


/i 


V' 


a 


I 


■  ...«ke  l,„  rc..„„,e,l  Z,U,   "Z      'uZ  "»■'""»'!« 

ide.  of  «o„„,*„„,  u,e  nee.     f;L"  I  r  r  1  ,0 
e..«.,  a„d  „po.  ,,.pl,ili.  „i„,ou.  .acriS,°,g  lir  fmf : 


mm 


izatioii.  In  comparison  with 
Mirope  specialism  ma-  truly  be 
ii'ctive  feature  in  the  medical 
And  It  ma.v  not  he  iiiapiiro- 
i  few  of  its  advantages  and  djs- 

een    is    that  which    shall   he." 
o  have  begun  with  specialisrs. 
argely  taken   up  with  the  con- 
ies,  and  centuries  later  we  find 
iials  treatincr  special  ailments; 
:es  a  "rectum  specialist"  in  a 
c  journals  would  "poke  fun" 
•     The  tail  of  our  emblematic 
ts  mouth;  at  no  age  has  spe- 
0  follow  its  gradual  develop- 
century  would  take  more  time 
"i  would   not  be  a  profitable 
i  of  knowledge  has  made  con. 
ssit)' ;  specialism  is  here,  and 

3  P'ofessioii  which  followed 
lowhere  been  more  striking 
lid  the  earnest  workers  in 
?y,  dermatology,  and  other 
;d  largely  to  inculcate  the 
ecessity  for  which  is  apt  to 
ry  and  bustle  incident  to  the 
r  work  b  done  all  along  the 


-   -...J    ..,.0  guiie  oy  lor 
although  we   have  a  few 


3 

ests  in  general  sur^erv   siifli  .,,.„ 

""fortunately,  from  t'  ;  ver '  T  ''''"''^'^h  '''^'^^  and, 
likUy  to  become  more  u  ,c  n  ^'"'"'"'n"^  "^  ""^  ^-'^ 
fo'-ting  tothegenerd  nr  M-  ""••  V'^'"  ''°^^  ''•""'- 
of  the  specialist/  We', :kr''''  "  ""^  ^^''^^  counsel 
>='ed  and  annoyed  us  the  .b  "•  "  T"  '^'''  '"'«  l'"^' 
fai...  and  we  cin  u?t  i  t  ^7'"  "^  ''^'''^'  ''  """''- 
o"'- experience  and  til  \^  ""written  records  of 

He  labels  hV^^i^^J""'^  — '^  "f  our  books 

a  beetle,  and  w^  fed' "  Sj^^f  °'"''-"*^^  """'"^ 
his  information   and    hun  ,v  i,    ..  '**   '*'='="'-acy    of 

'"bel.  And  if  som  ti  ;  '^s  '  r  ^','^'^0'.  of  the 
tween  life  and  .ieatl  )  he  f,  '"'!'"'S  ^'^e  Aaron  be- 
'larkness  of  our  i'  a  ce  1^""'  '°"  '""'^'''''•^  ^''« 
I'olden  to  him  for  ^::^2:.C.^''  "°^  ^^  "*"'-'  ^- 

in  w,;-2'rfi;nrzc^i'^:ji'-the  public. 

I'owever,  now  so  ge.ndZr"'" ''''"''^  "^''"'^'^''S^  id- 
lest the  familydocto  s  o.  i  "'  "  ^  »'"''"«  •^«"«er 
relic  of  the  P^  It  n^T  lee'ST'' '"  'T'  ^^'''^'  '- 
sands  to  feel  that  in  thl  !  -'           ^®  '^  *'''"'^0''l  '«  H'ou- 

pen  skill  i.  z^:  :  rrjiLT^n^'f ''  ^'■^^'  -- 

cialists,  no  class  in  our  profession  h  ,  ^  '''"'P^'  ^^  «'«^- 
abused  for  nu-dcllesomrwor  ^  f" '""'"'^  ™"'''">' 
aud  yet  what  shall  no    \l  t  """  g>  "geologists, 

a^  a  direct  out«  me  Tthe  verT^"'"  -^  ""^  ">^"'  «''o 
have  received  the  Wte  est  -'."P'''''^  '^'^''*''«  ^''i'^b 
recognize  tuba    gesta^.f  .^  '^'^  '^'"-"^'J  '» 

"bid.  other  wise  ^w.Sr.'etdd'''/" '•''■'  ^''^•'"^  '''^^« 
bave  known   Kormad  1  .    ^'^l''''^  '"'^'^  been  lost?     I 

a.lelpbia  I'athoLic  SV  ^v  't  "'"  ^""'  ''  "'^  l^'"''- 
^'f  r"!.tured  tubal  ne^tne'  '"  °'"  .'^'^'^'^  ^-'''"''P'«« 
"O'k '(sudden  deatli;  T  SeS  -'  "/  "'•^l!'-' '««' 
tbe  public  reap  from  sneci^  ,n  "  *  ■  '  ^""^'^'^  ^^'"'^b 
1    rom  specialism  may  be  gathered  from 


V^: 


the  fact  that  iu  a  not  much  longer  period  of  time  I 
have  seen  seven  specimens  of  tubal  gestation,  not  re- 
moved by  the  pathologist,  but  by  the  gynecologist, 
with  the  saving  of  five  lives.  The  conservatism,  wliich 
branded  ovariotomists  as  butchers  and  belly-rippers,  is 
not  yet  dead  among  us,  and  I  say  it  frankly,  to  our 
shame,  that  it  has  not  always  been  professional  encour- 
agement which  has  supported  the  daring  advances  on 
special  lines.  Humanity  owes  a  great  debt  of  grati- 
tude to  the  devoted  men  who  have  striven  during  the 
past  h'llf-century  for  exactness  in  knowledge  and  for 
its  i<ractical  application  in  all  departments,  a  debt  too 
great  to  pay,  too  great,  one  sometimes  feels,  even  to 
acknowledge. 

Specialism  is  not,  however,  without  many  disadvan- 
tages. A  radical  error  at  the  outset  is  the  failure  to 
recognize  that  the  results  of  specialized  observation  are 
at  best  only  partial  truths,  which  require  to  be  corre- 
lated with  facts  obtained  by  wider  study.  The  various 
organs,  the  diseases  of  which  are  subdivided  for  treat- 
ment, are  not  isolated,  but  complex  parts  of  a  com- 
plex whole,  and  every  day's  oxperieuce  brings  home 
the  truth  of  the  saying,  "  when  one  member  suffers  all 
the  members  suffer  with  it."  Plato  must  have  dis- 
cussed this  very  question  with  his  bright  friends  in  the 
profession,  —  Eryximachus,  perhaps, — or  he  never 
could  have  put  the  following  words  in  the  mouth  of 
Socrates  :  "  I  dare  say  that  you  may  liave  heard  eminent 
physicians  say  to  a  patient  who  comes  to  them  with 
bad  eyes,  that  they  cannot  cure  the  eyes  by  themselves, 
but  that  if  his  eyes  are  to  be  cured,  his  head  must  be 
treated ;  and  then  again  they  say  that  to  think  of  cur- 
ing the  head  alone  and  not  the  rest  of  the  body  also,  is 
the  height  of  folly.  And  arguing  in  this  way  they 
apply  their  methods  to  the  whole  body,  and  try  to 
treat  and  heal  the  whole  and  the  part  together.     Did 


longer  period  of  time  I 
if  tuba!  gestation,  not  re- 
but by    the  gynecologfst, 

Tlie  conservatism,  which 
chers  and  belly-rippers,  is 
1  I  say  it  frankly,  to  our 
1  been  professional  encour- 

I  the  daring  advances  ou 
es  a  great  debt  of  grati- 
10  have  striven  during  the 
;s3  in  knowledge  and  for 

II  departments,  a  debt  too 
sometimes  feels,  even  to 

,  without  many  disadvan- 
lie  outset  is  the  failure  to 
ipecialized  observation  are 
hich  require  to  be  corre- 
wider  study.  The  various 
1  are  subdivided  for  treat- 
complex  parts  of  a  com- 

experieuce  brings  home 
en  one  member  suffers  all 
"  Plato  must  have  dis- 
li  his  bright  friends  in  the 

perhaps,  —  or  he  never 
g  words  in  the  mouth  of 
lu  may  have  heard  eminent 
who  comes  to  them  with 
re  the  eyes  by  themselves, 
cured,  his  head  must  be 
,'  say  that  to  think  of  cur- 
ie rest  of  the  body  also,  is 
irguing  in  this  way  they 

whole  body,  and  try  to 

the  part  together.     Did 


X 


you  ever  observe  that  this  is  what  thev  sav  '^ "  2    A 
^- whtch  embodies  the  law  and'thl  g/spe.  fof  sTe-' 

ranks  as   o  the  most  nLlv!        ^^^' T^""^'  '"  °"'' 
or  a  student   with  H  «  h    "'^  '  '"  "■'"'^''  '°  «"<=ceed, 

••orance  can  ^JiZ  '*'"  assurance  which  onlv  ig! 

^y^^^o^^2:zT'V''  '".""^"•'■^  ^"■•'•^' 

bers  of  our  profession  evi,.  M     "'!"■"  <'f  "«erous  mem- 

.»*;,';;  ™s„™  r„'.r  s "  r  °"  "■"- "  •  ^ 

There  is  nnf  «   .;,    1     1  '      '^  .V«  ken  leather?"^- 

does  V:t     arry  w  f  ^i  Tir:'""'^'  '"  ^'^''^  ''  ^^'-''^ 
lamentable    tSdeTc     '' ^l'^'''''^y^^\oi  >l.is    most 

pathology  rou         rVverv  p  t"';i,:'    "''^"■"'•'«>'  "'"^ 
tions,  and  exercised  i.  These  io^v  •'^"".""""^^^  ^'^''«- 

of  professional  life,  the';;ri;^fi J-   r:^,^^^^ 
-  Ch»rml,le., :  J„wetf8  translation.  '         ' 


„,,^-:fr»,.„,:; 


6 


and  can  never,  even  in  the  daily  round  of  the  most 
exacting  practice,  desrenerate  into  a  money-making 
macliiiie./  And  let  the  younger  of  my  hearers  lay 
this  to  heart:  scan  tlia  lives  of  say  twenty  of  the  men 
most  prominent  in  a|)ecia]  lines  of  medicine  and  sur- 
gery to-day  in  this  country,  and  you  will  tind,  with 
scarcely  an  exception,  the  'early  years  devoted  to^  an- 
atomical, physiological,  or  pathological  studies.  They 
rose  high  because  the  foundations  were  deep.  The 
most  distinguished  oculists  have  been  meti  trained  in 
physiology^aiid  pathology  ;  and  some,  like  Sir  Win. 
Jiowman,  have  had  rejjutationsso  pre-eminent  in  several 
departments  that  the  identity  of  the  physiologist  has 
been  lost  in  the  ophthalmologist. 

In  the  larger  cities  the  work  of  the  specialist  en- 
croaches more  and  more  upon  that  of  the  general  practi- 
tioner, and  this  condition,  though  in  many  ways  to  be 
regretted,  is  not  likely  to  be  changed.  I  have  known 
the  head  of  a  household  pay,  in  the  course  of  a  year, 
for  the  professional  services  of  six  jdiysicians  —  a  gyn- 
ecologist, an  occulist,  a  laryngologist,  a  dermatologist 
and  a  surgeon.  What  remained  after  this  partition  of 
the  general  practitioner  came  in  sixth  and  looked  after 
the  health  of  the  children.  It  is  interesting  to  note 
that  to  this  one  pertains  the  functions  to  a  large  extent 
of  the  old  family  doctor,  and  further  advice  is  usually 
sought  through'  him  or  at  his  suggestion.  In  the 
evolution  of  the  sjjecialist,  the  children's  doctor  is  the 
last  to  appear,  not  because  of  any  extreme  ditl'erentia- 
tion.  but  rather  he  is  a  vestigiil  remnant  of  what  was 
formerly  in  cities  the  general  practitioner.  May  I  not 
sav  that  there  are  members  of  our  Society  whose  in- 
terest in  their  work  is  largely  due  to  this  new  feature 
in  (ioiuestic  life?  In  tiie  (livision  of  the  household 
among  our  brethren,  the  children  alone  remain,  ami 
fortunately  their  ailments  are  too  diversided  to  allow 
much  specialization. 


a  peculiar  trait,  it. ,  ^  i;:"/'':;'-'" '"•'•''"-"-  ^ 
we-are-tl.e-,,eonle"stvl  f.  .'  ,  ""  '"  ""  "surelv- 
g'eater  mi  lij  em  1  h',  ^  ''=  ''""""'«'<'«  'i'^  the 
under  ti.e  careof  nen     if  '   ""  ^I'-culapius,  an.l 

be  able   to  set  fr  "cture  /'"' ''"'^'''''■='*^'  ^^''"">"«t 

as  well  as  fevt;  etn  ^  .  rwd','"  "',7'°".'  "''^^^  '""« 
of  the  bene/its  ^f  s,  eci'li'sm  .f  ,'' /''"  '■''''■  '^^'"'t 
whose  ranks  the  cities  Hrl'l  'V  "V^"'^^'"''  <='"««  from 
is  so  essential  to  1  ^  at  o  '-""Sr''  ""'  T'"^'^  '"^"'"' 
ment   of  our  hosnitah    n,l?  "^  "ut-door  .It.j.art- 

Pi'Vsicians  tell  Se.ecs  "'?''""' -'T;™"""  ^^  ^"''^ 
tl'ese  people    n.rtir.,  ..I      ^  ^       ''"'''"''  k.iowlcige  to 

graver^a„.£r''  ',\t  l.;i:;"r^"''"?  =*""  '"  "'« 
tlius  avail  themselve  fom  b, u  T"' ''  ^'"'  "'°^«  *^''« 
bers  who  require  tednc' I  tn  /'"'T  °^  ^''«  "»•"■ 
diagnosis  or  treaLe.U  "  V l^'  i  t  faJ  Ih-'^T?"  "^ 
ed«e  enables  the  genenl  ll/J         '''''''"0"aJ  l^nowl- 

a  large  propprtiorfo  '  I'etse  vhl''.  '°  ^"''^'■''''^  "'""' 
under  the  care  of  the  sn  LS  '  t^' "^''  '".''•'^■'^^  «"«« 
"self  into  one  of  eduS  t^  ■  '■"  ''"'■'"""  '''"'^^^^ 
sessions  to  brincr  ?!'  k!  '    /S"  '™I'"-^sible  in  three 

but  in  a  ..or'e  Ironed  jri  "'\-|'-"-^'  -"^"'«' 
perieiice  —  the  stnd^n/  ^*'"',«<^  — as  I  know  from  ex- 

tbe  wards  an  ]  d    nnn      •        ^'  '""=''^  I'ractically,  i„ 

to  work.  He  shouh  Lil  ',f  fo<';"lat.on  upon  which 
practical  application  of  ^h         "  '"-'''""'^  '^""^^'"S  the 


8 


/i^ 


Ii 


man,  ill  general  practice,  sliould  know  a  "clioked- 
disk";  the  exiimiiiation  for  tiihe-cast8  slioulil  bo  a 
fumiliur,  evt'i-y-day  task;  and  he  sliould  be  able  to  tell 
whether  a  vocalchord  vva^  paralyzed.  A  surioiis 
obstacle  to  this  liajipy  coiisuniination  —  whicii  can  bo 
reached  in  a  well-ordiM-ed  system  of  education  —  is  tiie 
absence,  in  the  early  years  of  practice,  of  material  upon 
which  to  freshen  the"  memory  and  to  "  keep  the  haiul 
ill  ";  but  the  man  who,  as  a  student,  has  reached  a 
certain  point  always  retains  some  measure  of  the  old 
facility.  Tiie  post-graduate  schools  have  done  much 
to  enable  men  to  revive,  and  to  acquire,  technical  skill, 
and  have  been  of  great  service  in  generalizing  special 
knowledge.  In  the  practice  of  a  good,  all-round  man, 
the  number  of  cases  demanding  the  help  of  a  specialist 
is,  after  all,  not  great.  The  ordinary  run  of  nervous 
disorders  shouhl  be  recognized,  adenoid  vegetationa  he 
would  treat  with  the  skill  of  a  laryngologist ;  he  would 
know  enough  not  to  tinker  with  a  case  of  glaucoma; 
and  though  he  might  not  diagnose  a  pus-tube  from 
tubal  gestation,  he  would  (in  this  as  in  other  details) 
have  it'arned  to  know  his  limits  and  be  ready  to  seek 
further  advice. 

With  the  revival  and  extension  of  education  the  ben- 
efits of  specialism  will  become  more  widespread,  and 
to  this  end  the  efforts  of  colleges  and  hospitals  should 

The  organization  of  societies  for  the  study  of  partic- 
ular diseases  has  been  of  late  a  very  notable  feature 
in  the  professional  life  of  this  country.  Since  the 
foundation  of  the  Ophthalmological  Society,  more  than 
a  dozen  associations  have  been  formed,  and  their  union 
in  a  triennial  congress  has  proved  a  remarkable  success. 
These  societies  stimulate  work,  promote  good-fellow- 
ship, and  aid  materially  in  maintaining  the  standard  of 
professional  scholarship.    They  are  nearly  all  exclusive 


ow  a  "  clioked- 
;8  slioiiltl  l)«  a 
1(1  be  Jible  to  tell 
ad.  A  serious 
—  which  can  he 
ucation  —  is  tiie 
of  material  upon 
'  keep  the  hand 
,  lias  reached  a 
lasure  of  the  old 
lave  done  much 
B,  technical  skill, 
leraliziiig  special 
1.  all-round  man, 
lip  of  a  specialist 
■  run  of  nervous 
id  vegetations  he 
logist ;  he  would 
ise  of  glaucoma; 
a  pus-tube  from 
in  other  details) 
be  ready  to  seek 

ducation  the  ben- 
widespread,  and 
hospitals  should 

le  study  of  partic- 
■f  notable  feature 
titry.  Since  the 
Dciety,  more  than 
1,  and  their  union 
iiarkable  success, 
lote  good-fellow- 
g  the  standard  of 
larly  all  exclusive 


;fs£  e"i;:;;cJ;;/:;::;i;;i'j;:;;:;;-'j?^-H".Ji...  for  a.i- 

!'0  arb  trary  privilege  in  I'ki   "     "  '"?!'"^"  •''■^'^'•ci.se 
'f.V  with   the  .sul.iec?  ,.,  I       V'  ^  '"""'"I'ltes  familiar- 

-"'.'«.  i."t  the  unwr,","  p^  itilr'/''''''""^*^''-  ""'  "'« 
'*^  'f  they  were  ven.lor  o  " „  '  "  ""''  •"'"^f.  "ctin.. 
"'."•ket-plare.  "^  '''""*''^  '»  be  hawked  in  the 

of?;;Set;s,:Sin:r'''''^''.^^  ^'''' --"- 

'-"■^t  in  the  stu.iv  o      i  e  Lt,  ^''"V'^  y^''"^^  <>(  U, 
•^x'steiice  of  a  MH.oi.,1  '''*'■'»««.  of  cliiJ.lren.     The 

""'^  'he  ^ucce./;,",-  ,  of'"' .;  ""^"',  '°  "^"'■«^^^- 
''•~,sof  children  te  fv  ,«  .tr-'''"'*'?''''*  °^  "'« 
P="-t  ot  the  profession  of  the  V.    ">''"■;«"'''""  on   the 

'T''  ■^'"•'•V  "f  tl'is  rand  Tut"?  ""  ""^  '""'''^  ^-■ 
«'l'o  are  workin..  and  te.c  ii,.  ^'J!'^  "'^'^'••■'  '»  ««" 

t""ity  of  knowing  e^h  'u  '  '^.ri.r''^^'''''''^  -'  "CPor- 
common   inter...str  and  tW-h  "''''.'»  '"''J'-'^'^^  "^ 

f-'-biicationsmaki...  '  erair'  ^'^  '""""'"  "^  "'«'■• 
7'ue  ,n  practice,  fi.e  ■  ro'^l „     '""'"^  «l'«cial  details  of 

^'early  that  we  are  d^^Je^nn''"' ^?" '''•'''='*'«« 
and  may  the  character  of  M?  ^'''■«''''''   medicine  ■ 

'-.^'•e  best  }^^suS.:':'Z'::zr'  "'-"-"--ons 

zat'on  devoted  to  the  Ifn  ).  !•  "^'"'''  "^  'i"  or-ani- 
tJiat  field.  ""  ''"^>'  °^  a  particular  sectio,M-n 


/■^ 


'      s 


[ReprtoW  from  THE  cimATOLOOIST.^,  „sjj 


G   X 


I  K 


THK    irHAUNo   OJ.'  Tl.I,HI!CUmsj,S.. 
nv  WII.I.IAM  OSLKR,  M.I).,  ,,-  „  ,.  ,,    , 

'—""'—« --.■..'.:.:;;::;:,:,„ 

ti»..u. „,„i i,„di i i;avb:rfi  ;.:'''■"'' '" "■'""" ''""■■' *""' 

casco,,,  „rc.„,  ,,„„<,„„  i,„,,„.    '""•''''"  ^■'•->""«:  » I„. 

diticw  al,.„o  tl.o  (^.„,  '     ^"•""   "'"'  I'nic  salts.    T »o  ,.„„- 
•nJ  tli»  iLbcKlc  mav  tl,.,  l!^ ,            "        "'"'I''''  '■'"■•■'P»"l»t«l, 
«  ..«t  <lo,„-„v„.,.    ™L„  It  T   "'™'"'"'  "'  1"''-"'.  I'" 
l'»ali..g  i..  .1,0    r,,„      "J!;     !  ,'';■""  '■""'  •■'"■""•''  1"*«' 

a  eivity  „,„,.  bo  „o^fl .  i      /  i""'"'""  "'  ""^  ■™"."-tivo  Ik,,,,, 

lobe,  ,„  ,vbi,.b  ,bi,  „,   ,  ,,  ^,f ;■; ': "'™'' ',''»'  •-'"  "I'l'"- 

tlii-cl  it,  „„r,„„l  si,e  „„<l  „^  i    , ,.    'I'l'™''  "'V  be  only  „„o. 

Ti..o  a,.c^bo  ./o;:,;:Xc:":rc,,:r'  "■'*"  ^■--■"^• 

;  R*"'"'  before  the  Mcdico-Cl.irurgical  Faculty  of  M      .      , 

'  Uennec,  Trait6  de  1' Auscultation    tnlr^''^'""^'  ''■''■'"■°"  °''  'S^'- 
1837.  "«cultation,  tome  II.,  p«ge  97,  4th  edition,  Paris 


1 

4 

I 

-,,  1 ' 

f 

^ 


tionn,  evi^iiotttUf  of  old  tulM'r.M.lar  Um\om  oociirml,  and  lim  wido 
dini.al  t'xporionoc  had  tuu};ht  liim  .l,ut  recovery  tcok  place  in 
many  cuhcs.  IF.-  re<'ogi.i/Hl  the  ricntriorx  rnmpltien  and  the  mca- 
lfi,'rs  jUlulvuH€H,  and  siipp>Hted  that  as  tiil.crch«  K'-^^vinK'  in  the 
glandM,  "which  we  call  HTcfula  "  often  healed,  why  Hhonid  it  not 
)|o '"HoHauic  in  Mie  Iwiij^s? 

K.w'cnt  studies  ha-e  nliown  that  in  a  considerable  |)roi)ortu)n  of 
the  bodieg  of  iK'rsons  d\inj,'  of  all  diseases,  <iiiiesccnt  or  healed 
tubercular  lesions  are  fonnd  in  tli<'lnn-s;  a  i)n.i.ortion  so  hi^rh, 
inde(>d,  in  the  case  of  some  observers,  as  almost  to  jnHtily  the  (dd 
(;crtnan  axiom,  "  Jcdrrindnn  hat  am  Ende  dn  hinchen  Tubtrm- 

Imr." 

Mv  attention  was  called  to  thi'  point  in  1H7()  by  Palmer  How- 
ard, of  Montreal,  who  v.as  in  the  haltit  of  poinlin}r  ont  tin;  ^m^at 
fre(|nency  of  puckering  at  the  npices  of  the  lungs  in  elderly  per- 
sons. Snbse(piently,  when  I  became  pathologist  to  the  Montreal 
(ieneral  Hospital,  we  frerpiently  discussed  the  significance  of  these 
changes,  whether  indicative  or  not  of  healed  phthisis.  Wa  see  at 
the  apices  the  following  conditions,  all  of  which  have  been  he'd 
by  some  to  signify  healetl  tubercular  pro(!(>sses  : — 

1.  Thickening  of  the  pleura,  usually  the  posterior  surface  of 
the  apex,  with  perhaps  subjacent  induration  of  the  lung  tissue  for 
a  distance  of  n  few  millimetres.  This  I  do  not  think  indicates 
more  than  a  local  chronic  pleurisy,  and,  as  my  colleague.  Dr. 
Welch,  siitrgests,  is  possibly  analogous  to,  and  has  no  greater  sig- 
nificant! than,  a  milky  patch  on  the  pericardium. 

2.  A  puckered  cicatrix  at  the  apex  depressing  the  pleura, 
which  here  may  or  may  not  bo  thickened.  On  section,  there  is 
a  fibrous  scar  nnich  pigmented,  the  bronchioles  in  the  neigh- 
borhood arc  dilated,  but  there  are  neither  tubercles  nor  cheesy 
masses.  Such  structures  are  extremely  common,  and  may  in 
some,  but  I  doubt  if  in  all,  cases  indicate  a  healed  tubercular 
lesion. 

3.  Puckered  cicatrices  with  a  cheesy  or  cretaceous  central 
nodule  and  with  scattered  tubercles — "colonies,"  Laen  lec  enlleii 
them — in  the  vicinity.  Identical  with  these  in  their  true  iiuture, 
though  differing  in  the  general  appearance,  are  the  solitary  or 
cheesy  calcareous  nodules  found   throughout  the   lungs.      The 


ISSfS^S"*', 


■^!m^^rnT2:mSs;.W^SB^^^&*S 


z'^^m^?;^^- 


"'""'"'IMW  will,  l,„„„.„i  "''"'  ''^  "'""«'  "■'""«  uml  ,.„ra. 

;i''-''««M:':r£.;:™r,;:;i;7::!r'r'"''-- -". 

""  '•'"•->  «'.<'  tl.o  solitarv    1         ;    "7'  """  '"™'  '''-'-^"in^.  of 

''••'•-"  with  U.0  /i,.„.,,  ,,,„■,.  '  •'        "  :^'"  ='l'I-ar  small  i„  .on>- 

''!^f-tlyn,o,.io.K..lti;at  e  .    ' ;    :  V "  ^ '«  ^f^-  --  it  .-^ 

7'""^r-     Ofther>f,oaseMl<C      ';""'?  r'^"'""'-'^       '"  it. 

"'  vano,..s  organs,  12;   o  rrJ.o  i    of      •^"  "'^'''^'^^'' ^-- =  -ancer 

'•'-•••'^-S  «;  aculo  loves,  0  ,.:'  ^''T-  ^'  "'•'■'•'•-t«  and 
-"iarlone«,5;  other  alU.l  u's  •  '  V  '  '^'"""■^  «^' tl-o  heart 
»««'ll<>w.s:   .uKlerten   years  4     1     "'"  «^'^^«  «^  the  eases  ^-ere 

-nt,  to  thirty,  8;  fro.  thi;, 'to'b I   U)  ^V"-"^>^' 2;   /ro„, 

^'f  «  -.form  eriterion  as  to  wh  t  she,  IdT  "'^' '^  ''  ^"  '^'^--^ 
-•  q»'eseent  tnberdes.  If  the  fil  ro  ,  ^  ''''^''''^''^  "^  ""^^^'^te 
«J  -  some  of  the  followiu;  st  S'T"  "^  ''  ^  '•-'^•"'«'^, 
He,tler  analysed  the  Vienna  1,^'/  ^''''''''^S^  ^^  high. 
''•'^^'nlG,562..ases,inwhieh  tK  T  "^  '''''''''^'  ""^'  «>"nd 
''.V  phthisis,  there  were  780  ins  tees  of  T  r'  ''"'•"^'^  ^--<1 


»'fl 


;     ) 


I     !i 


'I 


f 


,.,..>^  funrul  ap.'x  cirrhosis  in  202.  Massini  found  ovi.lcnrcs  of 
lK,,lin-  in  ;19  per  cont.  in  22S  iH.dics  (..xnn.inod.  llarr>s,  ..f  Man- 
i.h,.ivv  iKis  ..xaininod  200  iKHli.'S  kcopin-  tliis  .)l)ic(-t  specially  ni 
viow  'j'Acl.Kling  tlu'  (icatl.s  from  phthisis  and  persons  under 
twentv,  there  were  left  l-!!)  cases  for  analysis,  in  54  of  wliicli 
there  were  relies  of  former  active  tuber.'nlosis,  ,'58.84  per  cent. 
Tin.  -roatcr  niinib.  r  of  these,  were  in  the  third,  lonrth,  and  fifth 
,|,vi(ies  'I'lie  lar-e  proi«.rtion  hero  given  is  accounted  for  by 
tJK'   inclusion  of  the   fibroid   cicatrices  as  well  as   the  caseous 

masses. 

I  heard  the  statement  made  in  Paris  that,  ot  the  bodies  exam- 
iunl  in  tiie  moi-iie,  the  majority  of  which  are  of  suicides  or 
persons  accidentally  killed,  nearly  seventy-five  {)er  cent,  present 
evidences  of  old  tuberculous  lesions. 

Tliese  facts  d(-moiistrat(s  first,  the  wide-spread  prevalence  of 
ltil)ereulosis;  and  secondly,  the  fiiet,  as  shown  by  my  figures, 
that  at  least  one-fourth  of  all  infected  persons  recover  sponta- 
iioously.  In  the  great  majority  of  these  cases  the  disease  is  very 
limited  and  has  made  no  progress,  and  in  many  instances  could 
not  have  given  physical  signs.  JUit  even  in  more  advanced  dis- 
ease, wIkh-c  the  local  indications  are  marked  and  bacilli  and 
elastic  tissue  present  in  the  sputum,  arrest  is  by  no  means  infre- 
quent, and  although  ])ost-mortein  evideuco  shows  that  wo  are 
wrong  in  speaking  of  the  process  as  cured,  yet  tlio  condition  is 
consistent  with  compaiatively  good  health. 

Wo  may  say,  then,  that  in  one-fourth  of  all  j)ersons  infected 
the  disease  is  never  manifest,  but  remains  local,  and  the  lesions 
gradually  heal.  In  another  fourth  of  those  attacked,  local  signs 
develop,  but  the  physiological  resistance  is  sufficient  to  arrest  the 
process,  or  in  modern  language  the  battle  is  against  the  invaders, 
the  day  is  with  the  tissues,  and  a  permanent  time  is  agreed  -ipon, 
or  sometimes  a  permanent  withdrawal  of  the  enemy.  The  re- 
maining fifty  per  cent,  of  those  infected  light,  for  months  and 
years,  losing  battles  until  the  final  defeat  comes. 

Tlie  nature  of  the  fimie  mil  is  the  important  factor  in  tuber- 
euiosis ;  the  seed  is  so  widely  scattered,  that  upon  each  one  of  us, 
sooner  or  later,  some  grains  must  fldl.  I  am  in  the  habit  of 
illustrating  this  poin*  to  my  students  by  the  parable  of  the  sower 


i 


tm 


?■ 


;;■'">  ^vont  out  to  sow  Lis  soci       T„  H.    l 

--"•'  ^.-oup  iU.  bacilli  /in,]  1,:,:    :,;  'f  'f  "'"  '-'IMi'l'^r  in  u 
^'"•'V'",  as  U,o  soil  conditions  -    ^  •  "n"™^''  '"'^  "'^-^  ^'<^  "»t 

"over  been  betfer  iHnstnUe.!  tl  b     iT  1  ^"^•''•-""-t  has 

"•;"  ^^-J  '-abbits,  eonfine.1  in  .  '^,  , "f  ^^''  «  -I'-'-t     Jn. 
;'"«t  others  allowed  to  roan'  !       '''"r'' '''•'■^''^'■^•'•'*-'''''''-', 

^I'glit  l,,.sionH.     It  is  the  lu  ^''  '''^''^''"  ^•^'•■"vere,!  or  h,\ 

'">"«-d  to  the  1.0.:.  t^'::: '""'""  ^f^'-^""«^'"^  ='  i''-^  ^ 

«^"'J^',  ill-vontilated  chvelj^  ^^  H;  """■''"'^^^'  '"""'-'  '••  '"  - 

-"m-,  whe..as  a  patient  livi,;  I    ;J  "/^     j    '""'""'  "'  ^'- 
«'^>aor  part  of  tU.  dav  lu,s  a  eh  a  ■     1  '1  f ''''^'''■''^' '"-  t'- 

'•al^i.it  rnnnino.  ^ild.     TJ,,  ve  v  ""'"'''-^''''''^  to  that  of  the 

l^'-^'«l'  air  and  snnsl  ine  are  tie  ^^.  """^'''"  ^^^  *'"vironn.ent 

p--,aitit..iei.oi..:o:x,;'?,;::;-^^ 


ya 


?  M 


* 

4 


n«M 


Published  the  iSth  of  each  Month. 


THE 


o: 


CLIMATOLOGIST. 

A  MONTHLY  JOURNAL  OF  MEDICINE, 

DKVOTKP   TO  THE 

Kelation  of  Climate,  Mineral  Springs,  Diet,  Preventive 

Medicine,  Eace,  Occupation,  Life  Insurance, 

and  Sanitary  Science  to  Disease. 

Edited  by 

JOHN  M.  KEATING,  M.D., 

FREDERICK  A.  PACKARD,  M.D.,      CxIARLES  F.  GARDINER,  M.D. 


JOHl 


ASSOCIAT 
VmrKNT  Y.  BOWDITCn,  M.D.,  U.)ston,  Mass. 
NOKMAN  lilUIHiE,  M.D.,  I.os  AiiK'olfS,  (.'ill. 
PETKU  11.  liUYCK.  M.D.,  Tiininto,  Ciiiincla. 
SAML.  K.  BrUKOrOHS,  M.D.,  Kaymoml,  Tpx. 
,1.  WEI.l.INfiTdN  liYEKS,  M.D.,  Chiirliilto,  .N  C, 
.1.  M.  DaCOSTA.  ^r.D.,  I'liilndfipliia,  Pa. 
CHARLES  DEN'ISON,  M.D.,  Denver,  Colo, 
(iEORClE  DOCK,  M.D.,  (ialvcston,  Texas. 
WM.  A.  EDWARDS.  M.D.,  San  Diego,  Cal. 
J.  T.  ESKKIDHE,  M.D.,  Denver,  Colo. 
SAMl'ET.  A.  FISK,  M.D.,  Denver,  Colo. 
F.  FREMONT-SMITH,  M.D.,  St.  Augustine,  Fla. 
W.  II.  GEDDINiiS.  M.D.,  Aiken,  S.  C. 
JOHN  TKATI.l.  (iKEEN,  M.D.,  Tucson,  Arizona, 
JOUN  B.  HA.MII.TON,  M.D.,  Chicago,  III. 
T.  S.  HOPKINS,  M,D.,  Tlioniasville,  Ca. 

JAMES  C.  WILSON, 


E  EDITORS: 

FUEDEKICK  I.  KNIGHT,  M,D,,  Boston,  Mass. 

AI.EKED  E.  EOOMIS,  M.D.,  New  York  City. 

llENliV  M,  EYXLVN,  M.D.,  Chicago,  llLs. 

FRANCIS  MINOT,  M.D.,  Boston,  Mas.s. 
.    WII-LIAM  OSLEH,  M,D,,  Baltimore,  Md. 

WIl.MA.M  PEPPER,  M.D.,  Philackl|)hia,  Pa. 

liOAUDMAN  REED,  M.D.,  Atlantic  City,  N.  J. 

•T.  HEI:D,  Jr.,  M.D.,  Colorado  Springs,  Colo. 

GEORGE  H.  ROUE,  M.D.,  Baltimore,  Md. 

KAIU.  VON  RUCK,  M.D.,  Asheville,  N.  C. 

FREDK.  C.  SIIATTUCK,  M.D.,  Boston.  Mass. 

S.  E.  SOLLY,  M.D.,  Colorado  Springs,  Colo. 

G.  B.  THORNTON,  M.D.,  Memphis,  Tenn. 
.    E.  L.  TRUDEAU,  M.D.  Sarftnac  Lake,  N.  Y. 

J.  B.  WALKER,  M.D.,  Philadelphia,  Pa. 

J.  P.  WALL,  M.D.,  Tampa,  Florida. 
M.D.,  Philadelphia,  Pa. 


Si- 


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W.  B.  SAUNDERS,  Publisher, 

913  Walnut  Street, 
Philadelphia,  Pa. 


CAk~ 


O^V  THE  ASSOCIATIOX  OP  CON- 
GENITAL WRY-NECK,  WITH 
MARKED  FACIAL  ASYM- 
METRY. 

BV  WILLIAM  0SLE8,    A,  D         ' 
JOHXSHOPKIKS  HOSPITAL,   „.LTi;OKK,„„. 


R<-'printed  from 

Archives  of  Pediatrics, 

February,  1892. 


New  York- : 

«-J.Roo.nhv,P„„,hr.«oStat,on.r 
'3'9  Broadway. 


i    h 


f 

1 

tJ      s 

j' 

t 

METRY..  ^^^^^'^^     FACIAL     ASYM- 

'•V  WlI.r.lA.M  OSI.KK,    M.l,., 

■'■■"- ""i'i<- n„s,„.,i,  ,,,„.„„„.,.  „', 

encr'i^U;^;;:^^^^;;,;:^--^^^'^  condition:  ..In  .efbr- 
and  furt],cr  investi.  ,  ,  "tim  in'  v""'''^^'  °^  observation 
to  this  affection  tl,c  Ikvic  n ul  f.  V  ""I>^  l^^''''^""-^  -'^^•bject 
do  not  develop  as  on  t  e  /S  i,  '„?'•  ''''"  ^°"tracted  side 
's  a  want  of  symmetry  in  e  c'u  i  '^""'^"juence  there 
examined  from  tlie  fro,  ),'    ""^^'^''^^'^^^l''-'"  narrowly 

tlK-  other,  and  the  uhc  e  of  t  m^l  "  r''F''''>'  '"^^''-^'-  than 
■VT^aller  than  on  the  other  ,''i  "  V"""  ^'''''^  ''^"^  head 
p.tal  with  heart  ch'sease  a  wrv  ,  L  '''  '"'"'>'  '"  ^J'^^  ''os- 
and  this  remarkable  want  oPsvmm.r''''''^'  '"''""^  '"^="^cy, 
^"  a  yonnjr  lady  patient  V  tf''^' "■''''-''■>' '-"^''dent. 
grown,  this  dispropoti  ,'?•'';''"  "  "^''^rwise  well 
anc  face  is  clear  y  s  own "  It  i'  T  T'^'^  "^^he  head 
's  due  to  some  f^dlure  o  ner.  n  s  n^nJer'?'^'"'  ''^■'''''''  ^his 
t>on  m  the  same  cause  wlHchn-o  .?''"- '^'^  ^"""da- 

Hliether  the  contracted  nn,s  ij  it  '   f'        ".    ^^''•^"--ck,  or 
on  growth,  and,  if  so,  w],e  he     t  u         ^■^"''■^^ ''"   influence 

mastoKl  would  allow  developmetVl'''""  "^^''^^  '^t'-''-""- 
referencesto  it  in   the   liter^,r      ^^'''"  ^•^' l'''"ceecl."   The 

'-bitually  carrS;rinT^r.2sS"T'-  '^''^  ^--'  -- 
ch.n  turned  to  the  ri^d,  tevact  " ,  .  '''y^"^^^  ^'th  the 
pest  the  explanation  b3  them  ,  ' /y'  l^'^'on  to  sug- 
heavier  than  the  right.'and  tlTe tad' u''  1^^  /^'^^  '^'^'^  "a-^ 
Krummachers<  reports    wf-n  '''  ''c^'d  crooked. 


|AS':^^,y:;;;'^™j;>;5te,,,/'  ,st  ditio,,,  ,878, 

S  "  I!,rli„    Th.-sis  •■   ,8So       y   >'''•«"''■  vol.  .vi..  ,882,  ' 


A.neHca,.,...„atW.  Society,  U..,„,,.,„„,,^,^^, 

454. 


2  Osi.i-.k  :   AssiHiittit'ii  ,>/  (.\>iioriiitti/  W'ly-Ahrk. 

asymmcti)-.  In  tlif  •^ihoiuI  tlic  cliilil,  aged  twelve,  at 
alK)ut  tlic  a<,a'  of  two  \ears  lill  and  had  paralysis  of  the 
extremities  on  tiu'  r'it;hl  side.  The  sternal  portion  of 
the  ri'dit  sterno-niastoid  was  i;ontracted.  The  facial 
asjnunetr)-  was  strildii.i^;  \  er\-  little  difference  in  the 
extremities;    no   special    as\nMiu'trj-   in   the   two   sides   of 

the  skull. 

Stanley  lioyd  reports  a  case  of  a  L;nl,  aged  nine  years, 
in  whom  the  torticollis  was  noticed  shortly  after  birth. 
The  right  half  of  the  face  was  ilistinctly  smaller  than  the 
left.  Careful  measurements  and  the  accompanying 
photograph  showed  the  great  difference  w'hich  existed 
between  the  two  sides,  not  onK  of  the  face  hu.  of  the 
.skull. 

1^}-  far  the  most  imi)orlanl  conniium'cation  on  the  sub- 
ject is  by  C.  IT   Cioldiiig-Hird,"     who  reports  six  cases  of 
congenital  wr> -neck  with  facial  hemi-atrophy. 
The  following  case  lias  come  under  my  observation  : 
Margaret     (i.,    aged     fifteen,    a    well-grown,     healthy 
looking  girl,  with  good   famil\'  historv'.     She  was  well  as 
a  child.     Nothing  wrong  w.is  noticed  until  her  tenth  year. 
On  the  i8th  of  December.  lS.S().  she  fell  and  cut  her  chin, 
and  the  mother  states   that  for   two  weeks  she  held   her 
head  turned   to  the  right,  and    for   a   \ear  or  more   after 
this  she  had  wr\-iieck.     Tiie  following   >-ear   Dr.  Tiffany 
operated,    anil    there    was    temporary    benefit.        Subse- 
quentlj-  b\-  gymn.istic  exercises  she  improved  very  much. 
The  mother  is  positive  that  the  child   had   not   wry-neck 
when  )'oung.     The  as}'mmetr_v  of  the  face  has  been  noted 
for  several  years,   and    is   thought   b>-  the  mother  to  be 
progressive.     A  photograph  taken  at  four  and  a  half,  full 
face,  shows  complete  ecpialit)' of  the  sitles;  no  lowering  of 
the  eye  or  eyebrow  s.     A  second    picture   at  eight  and  a 
half  shows  both   sides    fairly   eipul    and    the  eyes   on  the 
same  level. 

Neck;  circumference,  ,^0.5  cm.  The  left  side  is  dis- 
tinctl)-  fuller  than  the  right;  scarcely  perceptible  scar 
above  the  sternal  attachment  of  the  sterno-mastoid.  The 
outline  of  the  sterno-mastoid  on  the  right  side  is  plainer 
than  on  the  left  when  the  head  is  straight  and  the  depres- 
sion between  the  two  portions  is  better  marked.  The 
muscle  on  the  left  side  is  distinctl}'  larger  and  fuller,  and 
is  of  greater  breadth;  particiilarl)-  well  seen  when  the 
head    is    rotateil    to   the    riglit.      The    clavicular    part   is 


\  Illustrated  Medical  NeioSy  l.ontloii,  1889. 

\Giiy's  Ih'SpitttI  Reports,  Vo!.   xlvii,  l8ijO. 


«i( 


n 


Sf.KK 


Iss 


'"ull    and    strniu'-     111,1    h, 

between  the  ^^^l:;.^!!^.'^-'- .  of  the   d 


licad 


••^ncl  claviciil 


-^  rotated  to  the   left  tl 


ar 


ivision 


prominently  an.l  well.     \  ,     m!' 
P'-'^IUS  of  cither  side.  '''^^"' 

the   T'"^!"'  "»"  tl.e   hea.i 
die  left  r;if  iMi-    .«,...     ,1 


le  .sternal 
ence  a 


portion.s.     VVlicn  th 

portion  .stand.s  out 

Pparent  in  the  tra- 


marked 


9"tlicleft,side,fr 


:'^'  •"    uie   nead  .seem    free    h,,f     i 
'^■'-   more  than   to  the      .'ht      t,'''";  '■"^''^^^^  to 
=is>-mmetry.      The   r^^^^^iJ^^  ^^'l  ^^Iiovvs 


th 


!<-'  rnouth, 


IS  e.\a 


,     ^'low  theh.be  of  tl 


^jurements  are  as  foil 


ous: 


O'-i  the  other  sid 


-•tl> 


10  cm 


th 


us  to  th 


e  IS 


^'  tij)  of  the  antitr 


exactly  9.2  cm.     F 


corresponding-  ni 


eeartothean{,rleof 


c'asiirement 


om  the  outer  c 


an- 


-i^ntai  M,;„ .i;™;wi:.i":t;;;ii,."«/'';»4:  i.ft,  si^  a 


e.n-«;;r,,r";,:r;;;;'*.v^'-.i^ftp;»f 


at  the 

passin{,r  .it"che  "m 


.^'I'P^'-   lid   of  the  other 
■irk^'ii   of  the  1 


']"'  passes 


ej-e.     A  1 


ine 


passes  through  the  m     ,ih    '?':  '"^^'^'-   "'I   of  the  left   e  'e 
!;i?l>t  eyebro!;  is  t  T  dS  ,     ,  "UlSV^I'^^'^'^''     ^^^ 

owei    level   than  the  left. 


Th 


e  nose  is  strai-rht 


'■'<. '>n  a  distincth-  I 


Th 


'^Mvhole  cheek,  includ 


of  the  right  sid 


'"k^  the  malar  b 


^m^ 


Laugl 


■■t-'ncc    in    th 


^-^  IS  distinctly  small 


;one  and  zygoma 


IS 


c   ears 


Piipil.^ 


on  both  sides  of  he,-  t 
move   well.      A    littlr-  Vnf 
temple.  "'^    ^■^"'-■" 


are    e 


L'r  than  the  left 


no 


ace 
ill!'' 


Til 


qi'al,    react   alikt 
^■qua  Ij..     Jioth   frontal 
perhaj 


'■'^    in    the 


e  measurement  of  the   I 


right 


note  in  the  h 


equal.     No   mol 


ands  and  ar 


lea 


Th 


TI 


con 


palate 

le  question 


irs   in  the  I 


tl,    36.5 
ms.      Tlie  teeth 


Statement  that  the  chil 


i-:^  well  formed;   the  sid 
i^evs  whether   tl 
lie  mother 


ower  jaw   on   th 


cm.     Nothing  of 
re  well  formed. 


an 


es  o 


fthe  t 


igenital  wry-neck.     '\\ 


^'  right  side, 
ongue  equal. 


until   after   th 


f^'-^.  wa.s  really  a  ca.se  of 
'■'  ''^  quite  positi\ 


JJird 
info 


mentions  that 


ar    li/'i-    f.,..,iri.i  ■' 


e   accident  at   her   twe'lftl 


;rmed    that    the    ,\^U 
"ot.ced,  but  an   appeal 
eral  instances  showed  tl 
before   tl 


in    all   but 


e'  in  her 

■straight 

year.     Goldintr- 


ormi 


one   of  his  cases  h 


I"   appeal  to   the  phot 
^  '""'" "'lat  the  def, 


ty    had    onl)-    b 


ic  was 


'een    recently 


or 


kraph  album  ... 
mityhad  existed  1 


It.     \n 


in  sev- 


ong 


our   patient   the 


r^-topl^i'^S^attL'Srhalf  --^r-  --"-'^^ 
'-It  e.kht  and  a  half  years  si  w  in  '^  "''  ^'"^  P'^otograph 
not  in  the  earlier  one.  Li  1  e  ni  n  =''^>''"'"--try,  certainly 
some  have  said  the  sides  1  '''^^ure  ar  , >„.!,.  .„.,  .  .  L 
left  side  looked  th 


eight 


'acial  a 


e  smaller 


•^'ed   equal,  oth 


and  a  half 


crs    that  the 


iorPr!^^^>'^l-tc  evident  to  tl 


overlooked    b>'  tl 
familiar  with   the 


lie   parents  and   f 


'ic  observ 


er  may  be 


Under  th 


ese   circ 


appearance  of  i] 


riends,  who   have   be 


umstan 


le  c 


ces  It  1 


s  on 


ly 


hild  fr 


en 


om   infancy, 


necessary   to  sho 


m 


tlicin 


Om,i:k  ;  .hs( 

tlu'   icllcitinll 


ildtioll  iK 


f  ('<"l.<' 


iiilnl  ]Vrv-Ncck. 


)f  tlic  face  ill  tlic  lookinu-k'I'i^'^'  ^vliicli 


briii^^s  out  tlu    a-^; 
maiiiKi'. 


•mimtiN 


l.i't 


UfCIl 


tlu 


Sl( 


It's  in  a  strilsiiu 


All  of  the  Ciiscs  (.11  rcciM 


Sli^^ht    L;raclis 


lia\u  been  on  the  ri^lit  side. 


com 


iiion,  probal)])'  qu 


skull,  but  it  is  only  w  lien   e 
the  term  iiemi -atrophy  can 


)f  facial     asjmmetry    are    exceeilinj^ 
te  as  common  as  asymmetr)'  of  the 

that 


\treme  and    pro^n-essive 


)ln' 


e\ii 
atroj 
was 
same  g 


nnlieil  to  it.    'I"he  condition 

lently  is  quite  different  trom    Koniber-s    acial    liemi- 

In  none  of  the  cases  reported  has  the  umlateral 


tinL^    been   progressive,  nor  has    it   pniceeUei 


jrade  as    seen   in 
ob.serv'ably  chan^a'd,  an 


to   the 

iffection.     The    skin  is    not 

d  there  does  not  appear  to  be  the 


tl 


lis 


same 


loss  o 


f  subcutaneous  tissue,  nor  is 


there  uastini:  of 


the  sebaceous 
of  the  hairs, 
muscles   may 


follicles,  nor  any  chaiiye  in  the  nutrition 
The  differences  in  the  bones  and  of  thc- 
how 


ever,  be    \er\-   strikinL,^  i 


n   the   form  at 


present  un 
In  the  cases 


der  consideration. 


with  torticollis  the   c< 


iiulition  is  rather,  as 


llkS  SUL 


rests 


W 

developed   propo 

ra 


as  I 


f  the  face  on  the  affected  side  had  not 


rtioii.itely,  so  that  it  is  arres 


t  of 


H'ow 


th 


ther  than  an  actual  atroph) 

A  perfectly  satisfactory  explanation  of  tins  a.symmetry 
and  of  its  relation  to  torticollis  has  not  yet   been  offered. 
(tiuoted  by  Goldini;-Hird)  has  si,,;!_;ested  that 
k    interfered    with  the    vessels  and 


E 


ulenbcr! 


the  position  of  the   nee 

nerves  passin^^  to  the  liead   ami 

but  this   tloes   not  seem    \e 


so  arres 


ts  th 


e   nutrition, 


vances 


r}-   likely.     Goldin^-Bird   ad- 

the  \iew  that  the  facial  heini-atroph>-  is  not  a  con- 

f  the  torticollis,  but  an   integral   part  of  the 

mmon  central  origin,  which  he 


uence    o 


seq 

affection,  both  having  a  CO 
believes  is  a  primary  polio-encephalitis.     He  states  that 
1  the  exact  similarity  between  congeni 


bearing  in  niim 


tal  torticollis  an 


d  a  case  of  infantile  paral)'sis  wi 


ith  t 


111  pes 


eciuinus, 


th 


e  cone 


lusion  is,  to  my  mind,  all  but  inevitable 


that  "caput  obstipum,    w 
toid,    wasting   (  "    " 


ith  its  contractured  stcrno-mas- 
f'the  facial   muscles   and  soft  parts,   and 

li 


even  of  the  bones,  forms  an  exact  copy  o'  alipes  equinus 
with  contractured  calf-muscles,  ill-nourished  soft  parts, 
and  in  many  instances  shortened  bones,  and  must  have  a 
similar  origin."  It  certainly  appears  more  reasonable  to 
think  that  the  heiiii-atrophy  and  the  shortened  muscles 
are    both  the  expression   of  some  central   lesion,  but   it 


IS     ( 


liffi 


cult  to    unclers 


tand, 


from  our    present  knowledge 


CuU 


ct)rtical 
Id  be. 


)calization,    exac 


tly 


wnere 


tl 


le     misc 


hief 


()si,|.:k 


''''""■'"^'""  of  Cm^i^nufal  II >t- AV,/: 


5 


ti-n  of  ..aropI,y  o,  ; he'-^;  J'  ',;\\7'\ -'-^^^        it  is  a  co,uI  . 

arrest  ,„•  in, pcHcction  i      L    I.     f '''''  "  "^  ""^  '^^^h'  an 
't  ^voul,l,  as  i„  Ko„,|,,  "x'''.\,  ,^^'-';'I''">-"t.     If  tlu-  former 

";anyoftI,c   cases   >x.    rec        ,,  ''^n^^        '^-■"  ^''-^--nt 

asynimetry  may  have  .level.med  Vf.       .  "' '^■'■^.'■"'^'-"'^' ■''"' 
facial  c<)ii,liti,,„  is  such  -.s  m       t      ^^^""^   ^''^'  '"J^'T.     The 

related  t,.  the  torticollis  is  :.V\V^^^^^^^^^^^  '"   -I'at  uay 


I  'i 


If^ 


CLKui^O. 


^'^^-^^U^c^tn^ Art ,  ^  .-^  .  /4^^ 


/e-e^e-^ciy 


^       //  ^ '  '^'^  '^^^  './^^ 


7C 


->;' 


^'^^A..^ 


///J^^^'t  ^l^:.U^-fs^/^tUc  ^JUw^^^^i^^^ 


^c^*jUidJ^  ^'Cj^jr/,  ikUJ^x^J 


'^^'^^^tc^.i^) 


7ff. 


I  :   , 


V 


^^^fe^ 


r 


J. 


yr^^ 


^. 


'^  r.  trT  '  I^^V*  J'rr>^  \^-4\  ^Irr**-,  /Jff. 


I 


/ 


^C'^^f'^^^'  /^^^-^^/-c  ^^-  >;w.  A./^.^^  ^^1 


^. 


^1U 


fc^//:  /^.^ 


*^^-^  //^. 


I'''  I  .' 


hi 


II M 


i:i 


fjii 


ill  I 


' 

■■^=   ■     ^ 

i 

p«  J. 

^1  |: 

' 

^9  1 

I 

:    J 

'   p  1 

'■ 

\'  1 

« 

/1i 

,*^ 

^y^^  ^ 


-'W^^ 


(  ^■^^^.aZ'/t^ 


^^ 


/ 
1 


<. 


y^^^c^  r"-^^- 


^-d*~c 


-^Yi^ 


"^A 


'^7^ 


'^«-^-^V_~*"9^^ 


'^/?£ 


■/;^v- 


^^. 


^^i 


'i' 


i'Vi 


-/-^tt-. 


m 


>%^^>. 


'-^    ^ 


CX~K 


-:  ^^i 


7^ 


INTERSTITIAL  PROCESSES  IN  THE  CENTRAL 

Nervous  System. 


By  .William  Oslbb,  M.D. 


H'' 


?1  i 


M  ■'  I 


^^TEUSnTU,  PROCESSES  m  THE  C... 

'^^RVOUS  SYSTEM  '"^^^ 


^y    WiLtUM   OSL 


EK,   M.D 


I    ! 


INTERSTITIAL  PROCESSES  IN  THE  CENTRAL  NERVOUS 

SYSTEM. 

BY   WILUAU  OSLEH,   M.D. 

Protenw  nf  McAieinr  in  hejnhm  Hiniti'.n;>  i'lUivriUii,  RiUlmore. 

liy  iirratifremeiit  witli  the  Rofcivu  I  have  agreed  to  confine  my  re- 
marks to  a  pn'seiititiou  of  certain  pointR  for  (UHCussion  in  eonneetion 
with  interstitial  processes  in  the  central  nerv-Ms  system.  The  snl)ject 
is  heset  with  difficnlties.  If  we  cannot  hope  in  the  present  state  of 
our  knowledge  to  dispell  thi  darkness  which  surrounds  it,  we  may  at 
least  get  an  inkling  of  the  direction  in  which  to  look  for  li(?ht ;  if  we 
cannot  expect  a  solution  of  the  problem  which  more  than  any  other 
stretches  to  tension  the  pia  mater  of  the  neurologist,  we  oan  perhaps 
get  a  definite  outline  for  our  ignorance,  which  in  any  question  is  a 
great  gain. 

The  connective  tissue  of  the  central  nervous  system  is  of  two  kinds, 
one  special  and  peculiar,  the  neuroglia,  derived  from  the  ectoderm, 
with  distinct  morphological  and  diemical  characters  ;  tlie  other,  de- 
rived from  the  mesoderm,  is  identical  with  tlie  ordinary  collagenous 
fibrous  tissue  of  the  body.  Both  play  impoitant  parts  in  uidurative 
processes  in  the  brain  and  cord. 

A  convenient  division  of  the  scleroses  is  into  (1)  the  degenerative, 
(2),  l/ie  inflanunatory,  and  (3),  the  developmental. 

Tlic  degenerative  scleroses  comprise  the  largest  and  most  important 

subdivision  ir   "hich  provisionally  the  following  groups  may  be  made  : 

{a)  The  common  atrophic,  secondary  degeneration.    Nerve  fibres  cut 

off  from  their  idioi)lastic  centres,  i.  e.,  their  ganglia,  die  and  their  place 

is  gradually  occupied  by  neuroglia. 

{b)  Toxic  forms,  among  which  may  be  placed  the  scleroses  from  lead 
and  ergot  and  most  important  of  nil  the  posterior  sclerosis  due,  in  pach 
a  large  proportion  of  cases,  to  the  virus  of  syphilis.  Other  unknown 
toxic  bodies,  as  in  p.rnicious  aniemia,  may  induce  degeneration  of  the 
nerve  fibres  of  certain  tracts.  The  systemic  paths  differ  in  their  sus- 
ceptibility and  the  posterior  columns  appear  most  prone  to  undergo 
sclerosis. 

(c)  The  sclerosis  associated  with  clianges  in  tlie  smaller  arteries  and 
capillaries.     As  a  senile  process,  a  sclerotic  atrophy  of  the  convolutions 


IS  one 

insula 

lation 

in  the 

the  pr 

to  whi 

tion   ii 

arteriei 

this  ])a 

'I'he 

sive  gr 

sonietin 

seconda 

tion  abi 

ilistolo^ 

trix   sin 

parts  of 

litis  or  1 

niay  be 

consetjue 

sibly  too 

t'ncephali 

How  far 

hemiplegi 

The  modt 

stitutiouaJ 

change  is  i 

tribution, 

Ntich  as  wo 

elements. 

sclerosis  an 

The  diseas 

cerebi-al  atf 

its  true  nati 

sion  now  an 

wiiat  is  the 

The  devei 

attention  hi 

writers  to  pi 

heretofore  o 

cortical  sclei 

condition,  w\ 


;;•  ^'-"•••ai"  an  in  the  other  or^u  ;      ;    ''''f/'f  '^  ^'-  q-ti,.„  ,.,ich. 

•ytcru-sy     This  i   wo„h,  ,,,4,1;;;    ;•'."<•  -'Pallan..  an.i  Hmalh-r 
.   ' '''-'  "</'''"""''^/v/  Nclerosc.s  cmI.,.,,.,,  .,  ,        • 

-mc.t.,„os  conf.,..,..lo.i  ,vith  t  ."        ,!'.•';     •"•"  "'"  <'*'^-'--atio"s. 
secondary  lonn  wind,  .lovolo      i   '  .     "'"'''  •''^'"'''  '''^'"'  i"to  l.s(,  thJ 
-.  about  tu„.o...  h.„.o,.    X  'V   :X;'7'"r   ^'  "^"*'-  '"«-'•■ 
HiHtolo^Mcally  ti.i,  i,  ,,,tl!:/      'f''  '•'"''^«'al.s,H.ssan.ltra,„,n 

*'-  -""-•  to  that  j  .  i^t;"'"''  r'"-'"'^  ^^''"  -  «'>.-..!: 
p-ts  of  the  hody.  ,.,,  the  s  :S^':,;;;;;^'^;  ,f  ^  -'^^Hio,.  i..  ,z. 

'>t.H  or  n.e„i„  ,,.,„,     ,..,,i^  '-^  »^        follows  a  prin.ary  e-.c-opha- 

""^y  "^^  termed  i„Ha„u„ator;  00^.?^'     ^^"  "'"^^'  '"—  -''i-l. 
con«e,ue„ee  of  the  action  of^h         il     ,?!,^^"^''*' "--'"•^  ^Vstc.n  in 
-hly   00  of  .y,,,,i,i,.  ,,,^  i,„,,,,  ,  ,         ',  "  ^  '.^'  «P^-c.fio  fevers  and  pos- 
eneephaluiH.     The  terminal  ev  m       1  ,     !'.*^''""'>'''''^''^  --'"^  ^s  a  polio- 
"o-   ar  that  mo«t  interesti  i  vl  Uv  tT      /  "•"'"■  '^■•^-'■^^--ve. 
;--Pfe,na  i«  the  outcome  of  a     ,m'!  ^^'^rr  ^■''""<' '""  i-'f-tile 
1- mode  of  onset  in  the  child  Ch  fever     "'?''"  '^  ^^"*  ^'«»^tful. 
«  'tufonal  disturbance   speaks    for  an    '  '^^"^■"'«'«»«  ''»"'*  ^narked  con- 

;'rf  "  ^"•*'^^''  «^'  variable  extnt  If  n"'"""'^  '^'•--^  'i^'-" 
tnhntaon,  the  meninges  are  adher  n  'an,n  f  7  ■""'  '"^"^  ^'^«^"''^'-  <'-" 
"""'•  '^^  ^'"»i<l  follow  an  ac,Ue  i  fla  nn  "  '"^^^"^\'"''''^"y  ^'-  ^'-lerosis  ^s 
^''-nents.  This  constitutes  an  ^ZT"  "'''  '^'^^'•"^''-'  "*'  ti-"e 
-  erosis  and  may  involve  a  few  otXf  ""^u"  "'^'''^'^^^  "^  -'•^^''-'al 
"'V^'^-ase  is  not  infrequent  and  .«  7  *^"'^'' "^  ^"  «»t"-^  Jobe 

.--bral  affections  of  chihre"  mI  T'  ''  ''^  '"'^^^  -'->"«  "^  ai 
'  «  t-e  nature  and  with  this  I  wo!^  1  / T'""  ^J"  *^'^'"  "'-"  -  to 
->n  now  and  for  research  hereaf  t,.       T'""'^  'l"'"'*^""  f"''  ^"««»«- 

-i'a   .  the  nature  of  the  primary  eXnMrfl"'  "'"""'-^  «^  ^•'"''''•-> 
rhe  e/«.e/.^,,,,,,,„^  ^^,,^^  y  '^   «n?  "'«'*n"natory  or  vascular  v 

»ttent.on  has  been  paid  and  an  mJ  .^7  "Z  ^^'^'^^''  "^"  '^^^  special 
enters  to  place  them  in  a  oosiH  .  ^  """  ^'-'^^^  "'a''^^  by  French 
l^-etofore  occupied.     Tl  e'besr  ^^    ""'""""'^  ^^'''^"'  t'-e/have  .^t 

-ti^i  «derosisof  chiidinThi':  ::..^::^;f  ^V""  ^^  ^-"^- 

— ^  -en  .  may  appear  ^aU^e^  ^l^--— ^^^^t. 


hi 


Ufl  INTERSTITIAI,    PR(K'KSHKS    IN    TtrK    NERVOUS   SYSTEM. 

ncciirriiii,'  hxU-r  in  lift-,  ,u'rii<liially  |)n)(liu'os  atrophy  of  one  hcmisphorc. 
In  Hiicli  iMst'H  tlicic  maybe  ii"  involvt'iiu'iit  of  thi' iiit'iiinf,'t'H,  no  cvi- 
,l,.,icf  of  clwonic  iiitlanimalion  an.l  tlif  process  Hft'ins  fxplicable  only 
on  till'  •iiip]io«itiot\  or  a  .Icvclopnifiital  <'iTor,  a  vice  of  coiiHtrnction 
U-ailin^r  to  prourrcNt.ivf  incrciiM'  in  Hif  ncnrou'iia. 

A  swonil  fonnisllu'  wvW  kwnwu  ^(rowMi  about  tiie  wntral  canal 
which  conhtitutcs  tlic  anatomical  baniH  in  Hyrinp;o-inyclia,  the  OHMcntial 
factor  in  wliicii  is  an  cnormons  proliferation  of  the  ncnro.^lia  of  the 
central  itray  matter.  The  term  (//ioxis  has  been  ajtplied  to  this  variety 
which  is  now  very  generally  retrarded  an  u  lei^'t.n  (Pevolntio/i. 

Thinllv,  an  intercstinj,'  attemi>t  haw  been  made  by  Dejerine  and 
Lettdle  to  scpar.itc  Kriedrich's  ataxia  from  the  ordinary  form  and  to 
place  it  anionif  the  dcvelopnx'iilal  scleroses.  This  disease  is  dintiii- 
giiished  from  Romberfi's  tabes  by  its  early  onset,  its  occurrence  in 
members  of  the  same  family,  and  accordiiiL'-  to  the  authofH  just  named 
by  definite  iiistolo'^ical  peculiarities. 

And  lastly  a  most  intcrestiufjf  study  has  been  made  by  Chaslin  on 
the  brains  of  ej)ileptic8  on  which  he  claims  to  have  found  a  sclerotic 
change  of  a  distinctive  kind  (]uite  apart  from  the  ordinary  form  and 
su^o'cstive  of  an  association  with  a  i)rimitive  fault  of  construction. 
The  assertion  is  made  that  in  these  varieties  the  histological  element  is 
|)urely  netirogliar,  not  admixed  with  ordinary  connective  tissue  as  in 
the  other  forms.  It  is  in  fact  an  cctodermic  not  a  menodermic 
sclerosis. 

These  statements  have  not  passed  without  sharp  criticism,  particu- 
larly by  Wcigert,  who  denies  the  special  characters  of  the  anatomical 
changes  in  these  affections.  The  sul)ject  is  still  an  open  one,  fresh, 
and  of  jieculiar  interest,  and  I  would  propose  as  the  third  question  for 
discussion  now — and  to  some  foretliought  and  woik  hereafter:  How 
far  can  we  recognize  in  the  scleroses  of  the  brain  :ind  cord  a  separation 
into  an  cctodermic,  purely  neurogliar  form,  a  mesodermic  (connective 
tissue)  form,  and  mixed  varieties  ?* 

*  Ulubtrationa  were  shown  uf  the  various  forms  of  cerebral  sclerosii. 


CJryj  I 


™'  '"' T?'S  MEATMEN!  OF 
TYPHO/D  FEVER.' 


c 


(Jkntj.K.ukx  .    W'IjII 


ili-'UlIlst    I 


('     IK) 


IS  as 


to  ti 
of  tl 


prof 


OIlc 


H'  <'iiiv  oC  ,|i 
'lost;  w'lio  ,.|, 


cssidii   i'tn- 


••an    l)n'iio' 


's('a.s(;  l)v  (I 


I'llL'.- 


!irn> 


•  'xcivisr,  i'lvsl 


turn 


with    wate 


'  iiir,  1111 


"'liicli   tlu 


tliat 


"Oli-lllcJ 


'"'MlfCtfllo.    t|„,    j| 
"'<■    llHI.st    1)0 


•1    I'ailiiii 


accusation 


iiiii'> 


tliat 


pertain 


"'  virtncs  (I 


ic  iiso  of  natiT 


iciiial  anciit 


er. 


fcv 
and  tl 


1'  as  a   111,. 
'<»!■  contiirios  it 


cinand 


u'  M.ocld.v  the  rel,„k( 

N  -^""'l.  as  syst<'niati( 

'ic  atton- 


scaivcly  r('(,viv('  tl 


'"^   of  coi,tr„Ili„„.  tl 


''-•ii'ticMlarlv   is   U 


"<'  "SO  of  |,atli 


in  (I 


was  oil,.  ,,f'  ^1 


'«■  rlic  severe,. 


svin 


.«'<'  since  {Ii|),„„.,.;,t,,s.      Y 


isease  is  i 


'"'   i'atlier  of  ^[,,,i 


oil  will  fi 


.ureal 
■w'oiiiiiieii(l(M|  I 


IS   the 
iptoi 


(-■ase 
ns  of 


"yM'K'inV  moasi 


ii-e; 


■•'""'  "•*.'^  of  the  liatl.   t, 

Dm 
ill   tl 


'*'"'<^  ill!  adiiiirahl 


'"<!,  indeed,  in  tl 


>.\'  writers  i 


'1  ev(!ry 

'h'  writings  of 


:o  SOI 


■'»«■  the  first  half  of  t] 


,    TTH'  "'^^  *''«  "Hlieatio, 


:'»*■  "''  "'"V'l'  r  shall  refe 


is 


ic  /land 


^iiished   the  larm.  el 


of  the  Imlropaths,  I 


"■■^  cvntiiry  hv^h.^,t] 


'■  iiirain. 


'  '>y  which  term 


"■'■'PV'  was  largely 


upon  water  as 

'>i<'i.orinoi8te,-    Winter.iit/     I 


^^•^  of  hermaphrodit, 


;;---Il;l..itm,de,-tlieg„id 


pi'actitioiier 


may  l)<.  ^isti 


II- 


P''''sse.s,  (loiiehes,  and  tl 


iliice( 


'II'  varii 


"•""1,   and   others,   tl 


'"•<■  of  v(.n  Z 


■s  who  lo„|^ 


'icm.ssen. 


MIS    / 


Ih'aiid,  of  SU'tt 
'•.V  cold   liati 


, «.<imiis  lornis 


IC    ii.se    of 


'■^  of  baths  has  I 


"II,  iii'ii'ed  tl 


IS. 


Tl 


'<'  method  has  I 


.vstematie  fivati 


'•P  than  tl 


CO  111 - 

'«'"  intro- 


iirlv 


.\('ars  a 


.A  ( 


'ccn  siieeessfiill 


^^•'"<  of  typhoid  i 


yo 


ever 


l"'i<'"l   I.c'cl.ire  doliviTwl 


\-  ( 


arried  out 


oil  a 


lo  (I 


l^''Pnnt  frn„Mlu.  .lA,v//..„/  v„. ..,'...  ^T' . 


life'/irnl  \ews.  VhUiul 


"s  Uopk 


lll.s 


""■''''"■•■'•  "'•■'^^■"'lH;r;!,i,s92. 


-tn 


|i  ,41 

J 


I 


large  scalo  in  (lormany  and  in  France,  but  in  England  and  in  this 
(iountry  only  .spasmodic  and  not  very  successful  eftbrts  have  been 
niadc  U)  encourage  its  use,  even  in  hospital  jmactice.     The  remark- 
ai)le  figures  ])ul>lished  by  Brand  in   1887  made  nie  determine  to 
adopt  it  at  the  earliest  possible  date;  but  when  the  wards  of  the 
Johns  Hopkins  Hospital  were  first  o})ened  the  arrangements  were 
not  adapted,  and  our  stiift'  of  nurses  not  large  enough,  to  carry  out 
tiic  nictiiod  tliorouglily,  so  that  for  the  first  year  we  followed  the 
ordinary  symj)tonuitic  and  e.vpectant  plan  of  treatment.     1   am 
not  myself  personally  responsible  for  its  introduction.     During  my 
al)sence  in  Europe,  in  1890,  my  former  first  assistant,  Dr.  Lafleur, 
now  of  Montreal,  after  a  visit  to  the  wards  of  Dr.  .J.  C.  Wilson  at 
the  German  Hospital  in  Philadelphia,  began  the  practice,  and  the 
hospital  is  under  a  lasting  debt  to  him  for  the  accuracy  and  care 
with  which  at  tlie  outset,  and  fbi  more  than  a  year  subsequently 
lie  supervised  the  details  of  the  ti'catment. 

Most  of  you  have  seen  the  application  of  the  method  in  the  wards 
but  I  shall  emph;isize  certain  points  in  the  procedure  by  having  one 
of  tile  patients  bathed  before  you,  so  that  you  may  see  the  minutise. 
The  ward  orders,  subject  of  course  to  modifications,  are  as  fol- 
lows :  The  temperature  of  typhoid-fever  patients  is  to  be  taken 
every  two  hours ;  when  above  102.5°,  a  bath  at  70°  is  to  be  given 
every  third  hour.  The  patient  before  you  has  reached  the  sixteenth 
day  of  the  disease.     Hv  has  l)een  in  iiosj)ital  nine  days,  and  has 

iiad  thirty-six  baths.     The  tub  is  wheeled  to  the  side  of  the  boxl 

a  practice  much  preferable  to  that  followed  in  some  of  the  foreign 
liospitals  of  carrying  the  patient  to  the  bath,  or  indeed  allowing 
Inm,  if  he  is  able,  to  walk  to  it. 

The  techni(pie  of  tlie  procedui-e  is  as  follows :  The  tub,  as  you 
see,  is  of  \\i<;\it  pnpier-vmchr  material,  and  even  when  filled  with 
water,  as  at  present,  is  readily  portable  on  wheels.  The  temi)era- 
tiu-e  of  the  water  is  ()8°.  Here  in  tlie  amphitheatre  we  sliall  reverse 
the  usual  |)roc(Klure  and  liave  the  patient  w  iieeled  to  the  side  of  the 
bath.  The  preparation  is  extremely  si/nple.  The  heavier  lm\- 
clothes  are  removed  and  a  light  sheet  is  thrown  over  the  [latient 
from  the  neck  down,  ('nder  this  his  night-shirt  is  removed,  and, 
if  luressary,  a  light  napkin  is  ai)])lied  (.ver  tlie  genitals.  The 
jiaticnt  is  given  a  small  (|uaiitity  of  whiskey.     Two  orderlies  will 


l>atu.»t  J:u,,po„,s  t<.  1,0  a  Ia,...o 
<'oinfortal>Iv  into  ti.e  butl 


3 


stiJI 


•'^V(".r.I  with  tho  sJu-ot.     Tl 


-"•     I'm;    .MI 

\v<'Il-nonnsh«l  man,  and  I, 


'.•.«.■««;*:  i;:,r;:^'"t!«-/° -^ 


fits 


Ilis 


very 


'**>  an  a'J'-ciisliion 


fbriii  for  thi 


s'>l>P<>rt  of  the  baoi<.     fn 


one 


las  a  sloping  plat- 


'■"  thin,  eni-iPi.,f.,l      .•  "•     '"  "loro  deJi( 

-  i-f'^-  A  doth .:.  ^r:;'i:':  'r  '^'^  -  ^--^-i 

l>«t;ent's  head,  and  with  a  sard  I  .''r''  "  ^^^^^'^^  "Po»  the 

1-t.ont,  ^vho  takes  the  baths  u^thour  nT  '"  """'"'-^"^  ^^-^^ 
'"avojust  heard  hini  say,  he  wo  d  n  V  "^  ^''''''''  '^"*'  ««  you 
fi-^t-on  is  now  applij'.;^  ;'    ,.  ^'■;^p'-- wann.     Systen/atic 

--'s  of  a  cloth  o,-  rndia-..nbb       v,^"  ""'  *'"  '""^'  ^  '>^ 
i^ttached  to  a  stielc.     The  fHetio  .'  .  ?'  *^^'"^'^"'"^»^'e  may  be 

""Portant  der;,..t  ...  the  t..  2^     I  ''^'f'  '''fardel  as  a  ^.^ 

p^-V'^  ^  •  '«*  «*  ^"" "^'  ^t' r '^"  ^'«"- ^-»  *''^ 

^-•••■onsly  ...,,,, I,,  irip^,o,,,,t^^  hid  "  '  '^'''^  "^  ''«  '«^'t  alone, 
-hen  he  said:  '' H.t  tie  pe^n  whT  "T  ['"^  ^^  P^-t 
'•'•^^'■•Jy  and  ..eserved  in  his  maml..  m?       '  '^'■^*''  '^''""W  Ih' 

'>"t  others  should  pour  the  w'^  '        f  ^'^  "'^*'"'"S  «-  ^i'n.^elf 

f  ^;'7!  should  nit  be  .::;m  ^ '  x;:  r "'  -"^ "'-"  -^^^ 

the  bed  .s  prepaml  fbr  his  reeeptio n       h    ''   M  "'*  ''  '"  *''«  ^'»t'>. 
;-'  -'^'-  *'--  -  old  linen  sh^t        fft^^^.''"'''^'!'  ^'-^'t' "  '^'anket 
^•^'•^twenty  ,ninut..s  the  patient  waslifl;^      ,7"'"""^^  '"  '^'  ^ath 

•'"'t.  heavy  n.„,  and  the  orderl  es  we  '       ,     "'  '"^  '"^  '^  •^*'''^"g'v 
•^omo  l.ttle  diffieultv,  owin.r  to  tho        I         '"  ''"'"^^  '^^  there  was 

"7'-  '-th.  This;  i.owe:t.  i2  ;::t:::?  1;^"^ "'-  ^"  ^'-  «-^ 

:""'  then  patients  eon,plain  ,f  "..,!.;•'  I'""  ^'•■^W>en,  but  now 
'"  ?'  ^^"^  ^^^'*''<'  '-th;  and  tlo^  L"'  *''^  '^'•--«  ^^  lifti..,. 
>;-t..st  possible  ,.,.e,  these  litt^"tJ,  ^  '  "  ^"1  ^'^^'  -^''  the 
"■;'  --•  is  now  well  wrapped     p    .1"     T''  ^'^"^'^  *^  '''Wn. 


j 


fia 


I! 


ill 


u'i 


ly 


•  ill  !■    ' 


1 


^ 


.il 


t(t  ten  niinutcs,  but  iiiidcr  dtlior  (•irciiiiistaneos  lie  m.-'v  ho  carcfiillv 
dried  !it  once.      Vdii  sec  tliiit  this  man  retains  a  jiood  color  in  liis 
i'aco.;  the  extremities  are  cold  but  not  livid;  and  be  is  now  bef)in- 
ning  1.0  shiver.    Very  often  this  shivering  is  distressing  while  in 
Jie  iiath,  and  one  of  the  most  unpleasant  features  of  the  system. 
li'  the  patient  is  verv  cold  and  the  shivering  is  exti-eme,  hot  bottles 
mav  be  applied  to  the  feet  and  at  the  sides.     You  see  by  this  two- 
hourly  teinperature-cliart   the  inHu<'nce  of  the  baths;  and  half  an 
hour  after  this  the  temperature  will  be  taken  again,  and  the  reeord 
made.     If  at  the  end  of  three  hours  the  temperature  is  again  above 
102,5°,  he  will   have  another  liatl.  sueh  as  you   have  just  t-een. 
Now,  before  the  patient  is  wheeled  out,  he  will  l)e  given  two  ounces 
of  hot  milk  with  a  little  whiskey. 

Prar'tically  what  you  have  I'een  in  this  case  is  the  routine  of  our 
treatment.     'I'iie  patients  receive  no  medicine  other  than  ahiohol, 
and  that  we  do  not  give  as  a  matter  of  course,  but  as  a  rule  only, 
Itefore  and  after  the  bath.     In  othei-  eases,  when  the  heart  becomes 
feebl(\  we  give  strychnine,  and  in  some  cases  digitalis  and  ether. 
The  effects  of  the  baths  are :  first,  to  reduce  the  fever,  principally 
l)y  i.iV'oriug  heat-dissipation  and  by  the  direct  action  of  th(!  cold 
water  upon   the  blood  that  circulates   in   the  superficial   vessels; 
secondly,  as  a  general  tonic  to  the  nervous  and  circulatory  systems. 
Perhaps  the  most  striking  effect  is  seen   in  the  lessening  of  the 
nervous   irritability,  the  favoring   of  sleej),  and   the  clearing  of 
the  mind.     In  patients  treated  early  by  this  method  we  rareh-  see 
the  dry  tongue,  inuttering  delirium,  the  subsultus,  and  the  other 
grave  nervous  ])lienomena   which   ai'c  of  such   serious  import  in 
ty|)hoid   thvvi'.     The  liaths,   too,  appear  to  improve  the  general 
nutrition,  and  the  patients  take  their  food  better,  digest  better 
iiud,  as  has  been  said,  the  vital  j)rocesses  all  seem  more  active.     Do 
not  suppose,  however,  that  you  can,  as  Brand  entluisiasticallv  says 
kec])  the  ])aticnt  in  an  almost  afebrile  condition.     An  ins[)ection  of 
any  series  of  carefully-taken  charts  will  convince  you  that  this  is 
an   imjiossiliility ;  the  temperature  rises  again  in  a  variable  space 
of  time,  and  in  some  instances  the  influence  of  tlu;  bath  upon  tlu' 
rectal  temperature  is  exti-ijinely  slight. 

An  important  (piestion  is,  shall  we  bathe  all  cases  indifferently 
whether  the  temperature  reaches  102.5°  oi'  not,  and  whether  grave 
or  mild?    When  the  temperature  does  not  reach  the  point  indi- 


<"''<'<J,  iC  tlic  |)iitiont's  condlfl,,,,  ;  •         i       , 

I  <  oMiiJlliiii      s    <inii(l    Mii/l    *^I 

'«"'•'".«■  tlu.  ,,nst  hv..  v«,rs   .„hI  I  .  .  '"  '"'"'  '""'  l•■•"•'■■'■'■ 

"-■  l.a.l  ..uns..  to  mnvtV      )         '""  '""'"  ^'"'  ''"  ''-<■  ■'"  anv 

'•^■''^•---^^^^v..  titi  T"r''"''^■•''-''^'•- 
<'vor  lH....,nus  vry  pn,„o„„..,.,,.      y,  ,  \. '  "'  "'•'  -•'-1-U'Mtly  Uu, 
.■on,  tlu.   „,a„   has   s„l.,s„,,,„„t].   In,     ,'  ''  '"'>'  '"'''''  ■""  'l"'- 

^I'o  very  o-ood  n,,.soM  that  ue    li         /:;"'"'''"''''''' "''■^  l''"' f-" 
<^"  tlH'  ..tlu...  hand,  ;,.  ,ll     „  •  """'^   '"'  '""'  ^''''  '•---. 

-■'--'<•  !-it..ti.;n  i„      ; 

'•"-'^;"<>tI.,.aMs,.  tlu.      hit        ;         '^""-"■'•'-K'-  iW.n.   tlu. 

^''^M'atK.nt«   in   i„,ds  20  aj  'nj";  7''r'"  ^ 

a''<--'>>'>t  oi-  lu.nu.rrl.auv.      I„  tlu.  ov..  i    *■',    '  "'■''•'  "'"'f<*'''  "n 

'«'ti-.  though  wc  do  s    '•  h  r   "'  '■  "  "'"^=^'''^'  *''  -"^  ^' 

-'"-i-Mtly  to  j„sti,V  tlu.ip  „,.  '     ZZ  ''""'"''""  '"•'•'■"^■•■^ 

's  .-.^ardo,!  as  a  special  (.ont.-.;  i„d  I'""';'"^""''  "-••  l>.'oiu.hitis 

'•'^"^  -"•'<  that  its  ,.n,I  •,       /      •  "■'^""•"'  ^"  '•'^'"-■'<^''''v  i"  I.OS- 

'■--  vonea,ui.vou;:.":;^:r 

"""  •'-■'foroiit  hospital;  uluVh,.^    '         "     '■"'"'"'"  ^'"'  ■^^^'^'^tics  i„ 
-thod  now  aviilahh,  "    S;;"'  '"•  '"'^ T"'-^  -"•'<«  <'"  this 

^'"■""'■•b-  ''  Follow  of  tho  Johns  Ho    '  '•/^'''''''•'  ''^  ^'levoland, 

•^'-v  Vopk-.     Tlu.s..  littl/l     .1  ;?    •"  '^'■-  '^■■'»""  J>anu.h,of 


f  fffi 


foiitnbiitions  to 


a  Hiilyc'ot  that  I 


las  iiul 


_v<'t   iviiclii'd  llic  iliiily  lives  of  (lie  doctors  in  tliiw  cotiiitiv.      I'racti- 
(•■■iliy,  tlic  morliility  iimlcr  the  cold-lKitli  trciitniciit  in  hospitals  liaw 
JH'cn  reduced  from  \-')  and  2(»  oi'  2")  per  cent.,  to  an  averaj^e  of  (J 
or  7  j)er  cent.,  takinii'  all  cases,  or  even  very  inneli  lower  if  the 
crises  are  sifii   cirly.     Indeetl,   IJrand   has   figures  that  show  an 
absence  of  mortality  in  some  1,2(M)  cases  in   which  the  treatment 
i)e>ian  beti)rc  the  liftli  day.     But  in  hospital  practice  we  vun  never 
expect  to  sw  oiir  patients  before  the  end  of  the  first  week.     At  the 
German   Hospital   in    Pliiladelphia,   where  the  method   lias  been 
f()llowed  most  accurately  i)v  Dr.  ,f.  (J.  Wilson  ;.,id  his  colleagues, 
lliei'c  wei'c  ninety-tour  consecutive  cases  treated  without  a  death; 
but    I    understand   from    Dr.   Wilson   that  this   remarkable  good 
liirdme  has  not  continued,  though  the  mortality  has  been  kept  at 
a  very  low  rate.     Our  own  more  limited  experience  is  also  strik- 
ingly in  liivor  of  the  method,  and  a  report  is  in  course  of  j)id)lica- 
tion  dealing  with  the  first  hundred  eases  S(»  tre^ited.      In  the  fii'st 
year  of  the  opening  of  the  hospital  there  were  thirty-two  cases 
treated  on  tlie  symptomatic  and  exj)eetant  plan,  of  which  eight 
dieil,  a  moi'tality  of  2o  j)er  cent.,  a  rate  unusually  high  even  for 
a  general  hosi)ital.     The  cases,  however,  were  of  unusual  severitv  • 
one  had  acute  hemorrhagic  nej)l)ritis,  with  profuse  hematuria;  one 
case,  admitted  at  the  beginning  of  the  third  week,  had  extensive 
doid)le  ])neunionia.     Two  cases  died  of  perforation,  while  another 
case  died  of  profuse  hemorrhage  from  thi'  bowels.     On  the  other 
hand,  in   the  first   hundred  cases  treated   by  the  cold  baths    the 
mortality  has  been  only  7  per  cent.,  a  refhietion  so  striking  and 
remarkable  that  it  nmst   l)e  attributed  to  the  good  results  of  the 
bath.     Kvcu  this  rate  of  mortality,  which  is  about  the  average  for 
hospitals  in  which  the  rigid   Brand  system  is  carried  out,  would 
l)e  considered  by  the  proposer  of  the  method  far  too  high.      In  the 
report  refi'rrcd  to  I  have  given  full  details  of  the  fatal  cases,  and 
it  will  l)c  noticed  that  one  of  the  seven,  an  old  man  of  seventv 
was  admitted  late  in  the  disease  with  extensive  lol)ar  imeumonia, 
and  as  the  disease  was  not  recognized  as  typhoid  he  was  not  bathed. 
Two  cases  were  adnu'tted  in  i'ela])se. 

You  will  be  pleased  to  learn  that  in  the  cases  treatal  this  vear 
we  are  still  gratified  with  the  irsults  of  the  method.  We  are  at 
about  the  seventieth  case  in  our  second  series  of  a  hundred  cases, 
and  oidy  six  of  these  have  died. 


•<i  I' 


r^astly,  or  siHH'ial   intomst  to  vo,,  „ 

''«v<>  l>eon  rapjKHl  over  tlu-  k„,u  ,"'"  '"  '"-'^'''^^  Pmotuv.'  / 
I"--to  p....ti..„  it  ,,,,  .,  :^:;,X^?  7-'<-  '-•  -yin,  tl.at  in 
'"'^■'•^  ^"  '^^y  that  i„  this   .,s  in  '      "   '   ^"W"-«'  it  is  n.or. 

'••''''•%'CM.fhis,.o„vioti,,„s,tho  'n  tl  "'■''  '"''"'''  '""'   '"'■^  tho 

7'^;  a  good  „,„.,,  intdli,.„ti;'   "S;  *    '"  '""  "■""'•'•'"'  ""«^ 
:;    tl-  pationt's  fi„,.ij,,   the  pra^iot^       " '  ""  "'  ^-•>  "-»'-.. 

'■•  favo,.  of  hydrotherapy  an       L       T     '"^'"-^  ''"  ^'"^  l>'-"^l"««i<>n 

'"-;  -i>,>o.t  of  his  ..on;:;  L'"\^;;;^;^'-'"-  '-■  ^^^  '«-t ,,,  tho 

-"-  ''owovor,  ho  ovo,.,.onu.;vith  .!^'"    'T' ""^ '''^"''^'^'^'  ^^''-'' 
My  preooptor,  Dr.  I{.  |..  i^  ,  •;'<-  J«it.onoo,  and  a  littlo  tact. 

-'  ^"   rntho..  sot  tho  vo.^'  ^  '.^''"^-^  '■-' to  toll  a  ston' 
'^-thod.     Ka,,,  i„  ,,,^:  u,>ti,;^^;"  ""-."«  against  tho  Hntnd 

'•'--''«  Papo..,  D.  Howa.       :'hi f  •■  """"  ''"  '""^''-^-"  ^^ 
.^'-'-  tho  fnll  dotails,  an,l  h-  ,  "'"T  ""  *>'I'''""'  ^^^vor,  had 

'"«■-"  a  snutll  town  in  Western  '"  ?  '.-'r  "'"  '^^^  ^''''•'  P'-a-tis- 
f^"  '- -<J  i"  Brand,  to  u^Zl^tu''  '"''  ^"""^''  '"  '"^ 
tvphoHl  fbvo,.,  „.hi,h  ou-nn-ocl  if  i  '!'''' ^^'^^  ^''^'^''•^^  easo  Of 
•f  ^'-^  ^— •     Th,.  poo,,  p    iol     ,  r;.     ;'"•  '^---"-t  ftnn-h-os 

"-  -  «t..on^,  that  ho  lofi  tLtr    S     ,    '^  ^^^'"^  against  hin. 
."^  a  vory  ronioto  .-ontingonc-v-  and  o  .'o  .f".     '"V'«''<'^'"t,  howovor, 


r  ' 


m 


! 


8 


here  ji  Icltci'  iVniii  diic  nf  my  olil  riiivcrsit y  Ilospitiil  liousc- 
|>liysicijiii-,  an  cMiciiK'ly  caiTliil  and  aMc  pnii'tilidiicr,  who  liiis 
Imtm  iisiui;  llic  cnld  lialli  very  liiitliliilly.  and  in  s|ical<in<i'  of  (nic 
('a>('  lie  >ays ;  "  I'lic  |(.'a\<'rs,  cntrcallcs,  sii|)|»licati(iiis,  and  last  hiit 
nut  lia~t  (■llicii\(,  ihc  lu-ly  \rlU  (il'diis  </\v]  at  I'aili  hatli  were  such 
as  iiol  III  Miaiciially  inrrca-'  lln'  rr|iiis('  nt'  (he  iicij^'hliorhdnd  ur 
strcnylhcn  In  any  uii'al  lAlcnl  ihc  ni'ini/r  uC  tiic  liiniil\-." 

W'c  hav(    liivn  ('iinur!iiii|;iiii|n  niirxlvcs  (hiriiij;'  the  jjast   twn  oi 
thi'rc  iiiiiNtlis  ili.ii  iiiii-   niiiiirnins  cases   lia\-c  hccii  dointi'  sn  satis- 
lilctnrily,    lull    yesterday    nne   nl'   llie    inevitalilc    accidents    (iccill'l'cd 
which,    in    ucneral    h  i--|(ilai-    nnisl    i    iiiiiiiie.    in   spile   nl'  Hraiid's 
statements.   In   iiceni'  iicea>innally   and    maintain    sniuc    nidrtaiitx', 
at    any    rale,    in     iy|ihiiid     liver.       Tiie    patient,    admitted    ahoiit 
the   scvenlh  day   <<{'  hi-   ilhics-,   was  a   struiin',   well-hiiilt,   healthy 
man.  iii^cd    lhirty-se\cn.      lie    was    hath(d    from    the   time   of  his 
enlry.  and  had   had  almnt    forty  hatii-.      The  (hiy  iiefore  vcsterdjiv 
the  pidsc  \\a-  licidc  .and   I'apid  al'n  r  the  liath,  and  it  was  thoniiht 
ad\■i^ahle  In  nrdci'  the  lialh--  In  he  ih'-ennlimieih     Thd'e  was  a  little 
tenderness  in  the  alidninen.  Iml  nnihini:  very  striking.      Vestei'dav, 
as  Slime  lA'  ynu  saw,  the  si^ns  ii\'  perliuatinn   wer'c  well   marked, 
and   nf  tin-  he  died.      I    -Imw    ynu    here  the  small    intestine,  and 

ynu   will  -ec  a  <ninc\\lial    -n;d  mid  ivmarkalile  pietiii'e.      There 

is  a  -mall  -Imiuh  near  ihe  ilen-cccal  \alve.  and  there  are  two  or 
three  sin.all  ulcers  in  ihc  lir-i  |i;i||'  ;il„ive  th(.  valve.  There  ai'c 
also  one  III'  t\Mi -wnlleii  -iilii.ary  llillides,  hiif  there  are  also  sevei'al 
patches  which  shnw  -imply  ihe  -h.aveii-licard  appearance,  and  the 
lymph-elements  arc  imi  iheinselvcs  s|icciallv  swollen.  At  a  dis- 
lance  of  :!(lein.  I'mm  ihe  valve  lliere  is  a  sin.all  pcrf. ration,  resnltiiit.' 
linm  the  extcn-inii  nf  ;i  small,  deep  slniiiih  thrniioh  both  museuJar 

'"!''-•      Iliuher  lip  there  an ■  two  >mall    ulcers,   not    lariici- 

than  |)eas,  and  .almvc  ihis  ihciv  arc  j'eycr's  palelies  nninvolved, 
with  scarcely  any  inliltralioii.  The  -spleen  is  very  miieli  enlarged 
and  soft.  Here  was  a  patient,  wilhoiii  extremely  hii-h  tompera- 
'III'''-    liiilhed    from   alimil    ihc   scvenlh    day.    with    everv   tavoralilc 

|'i"'i''"'i"ii-iii''  •!-  <li''  •• 1'-.^   -hnvved.  cMremely  .-lioh'i   ulceration 

in  the  ilcnm.  and  vd.  owiiii;  no  d,>iil,|  (,,  |,„.;il  conditions  in  tin- 
limited  area  involved,  ihe  msi-  |i:i,|  extended  deeply,  and  pass- 
in-  throimh  linth  muscular  cals,  the  inevitaMe  perCrati'oii  ocenrred, 
with  lalal  pci'iionitis. 


I    i 


TEACHER  AND  STUDENT. 


AN    ADDRESS 

THi,  University  op  Minnesota 
Minneapolis,  Octobeh  4th,  1892* 


BY 


WILLIAM  OSLER,  M.  D.,  P  R  n  P  T 


Baltimore  : 
JOHN   MURPHY  &  CO. 
1893. 


B  ii       ' 

■  t     I       I   ! 


'^  f^f  f  ! 

1 

1 

^Mf 

1^^                 "    '    '    1^ 

A  University  conslit.-,  and  lifts  ever  ciniHlBti  il,  In  demand  and  Hiipply,  in  w.inln  which 
It  alono  oiin  satisfy  and  which  It  does  «atl.ify,  In  the  ooiuniunicatlcn  of  knowledge,  and 
therelalliin  and  Imiid  which  I'xislBlielween  the  teacher  and  the  taught.  Its  constituting, 
animating  principle  Is  this  moral  attraction  of  one  class  of  persorjH  to  another;  which  ia 
prior  In  its  nature,  nay  coninionly  In  its  history,  to  any  other  tie  whatever;  so  that, 
where  Ihls  Is  warning,  a  I'niversity  is  alive  only  in  name,  and  lias  lost  Its  true  essence, 
whatever  be  the  advantages,  whether  of  imsitlon  or  of  affluence,  with  which  the  civil 
power  or  private  hcnefactors  contrive  to  encircle  It— .IiuiN  Uk.nkv  Nkwman. 

It  would  siciii,  Adeimantus,  that  ihe  direction  In  which  education  starts  a  man  will 
determine  Ills  future  lifi'.— I'i.ato,  llfpiiblic,  iv. 


^^i:>n^ss. 


>'"""fe'  lives,  to  Hh-I    a  (Wr,     ,;      "\""^'^l'''"n'  l.rigl.tcocl   by 

"'"lt'.gra,luato  .students,  and  Jo  I.  1  7'  ''"  ^'"'''^  '''^'^^ 
t-t  i.in,,solf  with  the  d  ;  I  :  ":''f  """'•'"'•■"•'■'>•  '"  ""•- 
J'e  i..vitation  .as  a  ..-eaU    ,      ;"    "^^  "'""'^'  '"'"'"■"^^-     ^hon 

%^-^  ''-.lied;  h,;;  2 r   :;:rr'''''^^^ 

all,  to  relieve  a  brotherlv  i,.  ,       T'      "'"'''"'  ''  '''  >'«» 
bmhren  in  the  camp  o's  '  '"^  '"'^  ^^'•^'■''  ^«  ''is 

^'^•ven   n,e  far  afield     1        '  '"  '"•^^'"^^  ^^'"■'■''  '-s  often 

^"•-Hlsand  pleasant  n;;::',,!r  ^""•''"'  '"^  ""^'^  -^''  ^ood 

On  ih  1/ot:;::  ::7r:hi^''^  ^'"'f '- "^ -•■'^i-t. 

and  public  areawaken  n!    to  n    ":  "'""  ^''^  P-'>-'-on 

cation,  n.y  choice  was  necc  a  1  r  'T  ??  "'  '"^'■^^'  -'- 
ever,  of  a  formal  presenta  W .  "  '  ^"''""^'  ''«^- 
medieal  study,  I    hall  ,d  *''«  ^^"'I't'ons  and  needs  of 

tion  of  some';;  :  f  ,    ;  ^^  -7-1  f  chiefly  to  a  eonsidera 

'"ct.ons  a.  teachers,  in  dealing  with 


>  tfi 


4  Teacher  and  Student. 

which  I  can  incidentally  touch  upon  questions  of  general 
interest,  and  can,  nioi-eover,  speaking  on  behalf  of  the  Fac- 
ulty, say  a  few  words  of  welcome  and  encouragement  to  the 
classes  which  have  assembled  for  the  year. 


I. 

Truly  it  may  be  said  to-day  that  in  the  methods  of  teaching 
medicine  the  old  order  changeth  giving  place  to  new,  and  to 
this  revolution  let  me  briefly  refer,  since  it  has  an  immediate 
bearing  on  the  main  point  I  wish  to  make  in  the  first  portion 
of  my  address.    The  medical  schools  of  the  country  have  been 
either  independent,  University,  or  State   Institutions.     The 
first  class,  by  far  the  most  numerous,  have  in  title  University 
affiliations,  but  are  actually  devoid  of  organic  union  with  seats 
of  learning.     J^ecessary  as  these  bodies  have  been  in  the  past, 
it  is  a  cause  for  sincere  congratulation  that  the  number  is 
steadily  diminishing.    Admirable  in  certain  respects — adorned 
too  in  many  instances  by  the  names  of  men  who  bore  the  bur- 
den and  heat  of  the  day  of  small  things  and  have  passed  to 
their  rest  amid  our  honored  dead — the  truth  must  be  acknowl- 
edged that  the  lamentable  state  of  medical  education  in  this 
country  twenty  years  ago  was  the  direct  result  of  the  inhei'ent 
viciousness  of  a  system  they  fostered.      Something  in  the 
scheme  gradually  deadened  in  the  professors  all  sense  of  re- 
sponsibility until  they  professed  to  teach  (mark    the  word) 
in  less  than  two  years — one  of  the  most  difficult  arts  in  the 
world  to  acquire.     Responsibility!    fellow  teachers  in  medi- 
cine, believe  me  that  when  in  the  next  century  some  historian, 
standing  perhaps  in  this  place,  traces  the  development  of  the 
profession  in  this  country,  iie  will  dwell  on  notable  achieve- 
ments, on  great  discoveries,  and  on  the  unwearied  devotion  of 
its  members,  but  he  will  pass  judgment — yes,  severe  judgment 
— on  the  absenc  of  the  sense  of  responsibility  which  permitted 
a  criminal  laxity  in  medical  education  unknown  before  in  our 
annals,     ^ut  an  awakening  has  come,  and  there  is  sounding 


Teacher  and  Student. 


most  Pr'im^slI'lnd^lt^ruiJh TiTir'''''""'  ^'"'^  '^^^"  «'« 
tion  refen-erl  to  began  some  t  v  /  '  '"""''■'•  '^''^  '-^^'olu- 
anceof  thePresi<Ie,:t  of  "  ,  -  f  'n"  '^"  '^  ^''^^  '-"i''-- 
of  fts  medioal  faculty  wit  J;  ;,  I'  ^^'"^'--•^'.'^t  a  n,eoti„g 
^on.o  i„  order.  Unive^i  ^  1^7 '7"™?''  ^"^^^  ^'^'^ 
Arts  remain  to-day  as  in    ho  "'''  ""'^  ^'"^  ^^"'oral 

l-ki„gtheteelHnY>aU^e  Iti  ;,:;'f'''^^  ?''''  ^'^^'-J-  -inores, 
Ti.e  advantages  of  thi!  ^^J  ,  "l^  ^  ^"«  Sol.ol.  .ajores! 
recprooaJ.  The  professors  i.T  ""'""/''•*^  "'^"'^"Jfl  and 
J--  "ot  that  independZ  '  ;  ,,^:;7-^'^-^'  ^f  ■"■"  -'''ool 
under  an  influence  which  te,K  s  "'"'  '^'°'^^'"'  '"'*  are 

.^-g''  Jevel,  and  the  spi  of  n  1^'  " ''^.^  ''  '"'^1^  ^''-'  ^^  a 
•-proves  the  standa  -d  of  vj  a  d""""'  '"  "^''^''  ^-""■•- 
further  <leveIopment  '  "  '''  ***''«"^'  «t'rauln.  to 

^"^-rirt:;^,rrt^^^^^^^ 

•"etl.«d.  of  teaching    th     i,    t  '"'!*  ''^"'■■^'  advances  in 

;aboratoo^,and,heL  L  ':  n  ^^"''^'"^"^'  ^''"'-I  and 
fo:naer]y  consisted  i„  that  de  Id  /'T'"''  "valry-nd.ich 
of  merit-all  these  .cl    ,„  .       I    """^'"^  "^  ^'^^^s  as  a  tesf 

of  the  honds  betwL  t  e  S.d  Tc?  'T  'r  ''  ^'^^'^^^"'"^ 
And  lastly  there  are  thelf/.  e     .    T     '"^  *^"^  University 
.'s  one  of  the  few  exl  1    'jt  h  "  "  '^' "''"''  ^'"'^  ^'^^i 
An.erican  Institutions  to  footer  „vL        .  ^  "''^'•=^^'f«'-''«tic  of 
n-'it  private  corporations  to    It  ,  '"'^''''''''  '•^"^^  ^^  P^r- 

*''«  P"W'o.  This  ide  ca  ,eJ  L  Z  ^'^'"^"^^'^  ""  *'-  Pa- 1  of 
strict.!  "-nufacture^  t  \e  :  7:r  '"""'^  ^^'^  ""- 
'--  of  the  qualifications    su  llv  f '^''^""'  'i"'^^  ^^gard- 

c<.mnMn,itie8--<,f  „hvs   i  .       ^  ^''  "'""^^'■^  '»  ^ivi^ized 

a  hospital  ward,  Jn^ :^:'^:j^:^y  T-  ''''  '-"  ^^^ 
eine  somewhat  in  th  j^l;  !/ f"  nf  ^"  *«  '^^"  '"^di- 
-cogni.ed  the  course  o    th      ,t 'i       f  t"?  ^^^^'^'"'^  -'- 


6 


Teacher  and  Student. 


was  inserted.  So  far  as  I  know  State  authorities  have  never 
interfered  witli  any  legally  instituted  medical  school,  however 
poorly  equipi)cd  for  its  work,  however  lax  tlie  qualifications 
for  license.  Not  only  has  this  policy  of  non-intervention 
been  carried  to  excess,  i)ut  in  many  states  a  few  physicians  of 
any  town  could  get  a  charter  for  a  school  without  giving 
guarantees  that  laixiratory  or  clinical  facilities  would  be 
available.  This  anomalous  condition  is  rapidly  changing, 
owing  partly  to  a  revival  of  loyalty  to  higher  ideals  within 
our  ranks,  and  pardy  to  a  growing  appreciation  in  the 
public  of  tlic  value  of  i)hysicians  thoroughly  educated  in 
modern  methods.  A  ju-actical  acknowledgment  of  this  is 
found  in  the  recognition  in  tliree  States  at  least  of  medicine 
as  one  of  the  teclniical  branches  to  be  taught  in  the  Univer- 
sity siijipoi'ted  by  the  people  at  large. 

But  it  is  a  secondary  matter,  after  all,  whether  a  school  is 
under  state  or  University  control,  wliether  the  endowments 
are  great  or  small,  the  equipments  palatial  or  humble,  the 
fate  of  an  institution  rests  not  on  tiiese ;  tlie  inherent,  vital 
element,  which  transcends  all  material  interests,  which  may- 
give  to  a  school  glory  and  renown  in  their  absence,  and 
lacking  which  all  the  "  [)ride,  pomp  antl  circumstance  "  are 
vain — this  vitalizing  element,  I  say,  lies  in  the  men  who 
work  in  its  halls,  and  in  the  ideals  which  they  cherisii  and 
teach.  There  is  a  jiassage  in  one  of  John  Henry  Newman's 
Historical  Sketches,  which  expresses  this  feeling  in  terse  and 
beautiful  language,  "  I  say  then  that  the  personality  of  the 
teacher  is  able  in  some  sort  co  dispense  with  an  academical 
system,  but  that  the  system  cai.not  in  any  way  dispense  with 
personal  influence.  With  in'laence  there  is  life,  without  it 
there  is  none ;  if  influence  is  deprived  of  its  true  position  it 
will  not  by  t'  se  means  be  got  rid  of,  it  will  only  break  out 
irregularly,  dangerously.  An  academical  system  without  the 
personal  influence  of  teachers  upon  pupils  is  an  Arctic  winter; 
it  will  create  au  ice-bound,  petrifled,  cast-iron  University,  and 
nothing  else." 


VHM 


Teacher  and  Student.  - 

Naturally  from  this  standpoint  the  selecf-on  of  .      ,        • 
the  function  of  the  hia-hp«f  ;  .       selection  of  teachers  is 

University.     Owinl  tl  W  V    ^T  '"''  '"  '^''  Regents  of  a 

-tain  of 'the  chZ'is   e     ^^^^^^^  '''^  ?'-'-  "^  -e„  for 

town,  as  the  salaries  in  no'f   ,     T't"''  '"  '^''  University 

;;esupp,e.ente;v:t::r:r^;;:trT'"r'^^' 
^:::^\::^  :^t:iif -^^^^^ 

the  very  best  men  a'"'.!^"!  7".  .  ^^  '"'''"  ^P-'—tl'^t 
is  gratifying  to  no  eh'h^,   •?"'''  Z'*^^'^''^'^'  ^'H'-»t„,ents.     It 

shown  any  special  titno  on  ^'^'^' ^''''^'^''  ^ho  may  have 
ality  of  the  it  lia  r";  :^:'"'""  '"  ^'"'^  ^•^■^1-^  t'-  I'-ber- 

the  stranger  was  greteVls  7  ^"'TV  ^^'^^"''^  ^^^'^ 
gifts  alone.     Not  the  1  L    ll  '"'^  ^"^'^''^  *'^'  ^"'^  '"^"^'-^I 

t-ught  by  a  great  u/erst^ 

1-ow  no  county,  an^X-U  .  ell  '^::^  ^'l  T""^^ 
sovereignty  but  that  of  mind  and  1  'm  ?'^"''^'  "'^ 
genius.'     But  it  is  diffic^l      '  T  ""^''"^  '^"*  t''«t  of 

opinion  an.l  the  Rey  t^  We  oft      .  "'"7  ^"  ^'''''^-  ^'»^^- 

development  of  a  University  a  i"  the  Tu  !  ^  '"■^'"^* 
tarian  institution.     \o  f„-n   ..f  h  .■^^''^^^oleth  of  a  sec- 

does  it  appear  in  your  si  ,  «  T  7"  "  '"^  ^^^"^•^'^*'  "- 
n^edical  faculties.  Micht  ,!  .r  V'T'^'"'  ^^'""^'^  '''"^^^ 
from  this  spirit  in  thet  t  ''  '^'^'  ^  ""^"^'^'^  ^''^^'oni 

Realty,  an.^  iri:em:m£;::  ^^'^^.:tr;r  ''  '''  ""''''-' 
were  from  London    Phihrl      f    '      V       ''"'^'^  "''"^'"ations 

•»  the  newly  o  ga"  f  Jd  ^  'd' f '  T'  ''''''''''''"■  ««  ^^^^ 
sity  of  Texas,  at^r  fr     fom  ,f "        ''  ^'"  ^^^^^  ^niver- 

'  And  not  only  in  this  respect  km^i  

the  gratitude  of  every  iover  of  hi.'e/e?;"  o:\TrT'"  ,  '"^  '^"^  ^^^^ 
a  foui-year  curriculum.  Harvard  l2Z\\^'^  "'"'^'"«  '""mpulsory 
versity  of  Pennsylvania  begins  ne,"':"°w'  "",""""•  ''"'^  "^  U"" 
th.rd  clas«  schools,  corresponding  to  tL  four  IrT  ^^  ''■^''  ^^'=°"'*  -^"^ 

S  o  tne  lour,  three  and  two  session  colleges. 


Teacher  and  Student. 


II. 


The  function  of  the  teaclier,  to  paraphrase  tin;  words  of 
Mattliew  Arnold,  is  to  teacli  and  to  propagate  the  best  that  is 
k..own  and  taught  in  the  world.  To  toadi  the  current  knowl- 
e<lge  of  the  subject  he  professes — sifting,  analyzing,  assorting, 
laying  dow"  principles.  To  propagate;  L  e.,  to  multiply, 
facts  on  which  to  base  principles — experimenting,  searching, 
testing.  The  best  that  is  kiiown  and  taught  in  the  world — 
nothing  less  can  satisfy  a  teacher  worthy  of  the  name,  aud 
upon  us  of  the  medical  faculty  lies  a  bounden  duty  in  this 
respect,  since  our  Art,  coordinate  with  human  suffering,  is  cos- 
mopolitan. 

There  are  two  asjjecti^  in  which  we  may  view  the  teacher,  as  a 
worker  and  instructor  in  science,  and  as  practitioner  and  pro- 
fessor of  the  art;  and  these  correspond  to  the  natural  division 
of  tlit  faculty  into  the  medical  school  proper  and  the  hospital. 
In  this  eminently  practical  country  the  teacher  of  science 
has  not  yet  received  full  recognition,  owing  in  part  to  the 
great  expense  connected  with  his  work,  and  in  part  to  care- 
lessness or  ignorance  in  the  public  as  to  the  real  strength  of 
a  nation.     To  equip  and  maintain  separate   Labora.  r'js  in 
Anatomy,  Physiology,  Chemistry  (physiological  and  i    arma- 
cological).  Pathology  and  Hygiene,  to  employ  skilled  teach- 
ers, who  shall  spend  all  their  time  in  study  and  instruction, 
requires  a  capital  not  to-day  at  the  command  of  any  medical 
school  in  the  land.    There  are  fortunate  ones  with  two  or  three 
departments  well  organized,  not  one  with  all.     In  contrast, 
Bavaria,  a  kingdom  of  the  German  Empire,  with  an  area  less 
than  this  state,  and  a  population  of  five  and  a  half  millions, 
supports  in  its  three  University  towns  fJourishing  medical 
schools  with  extensive  laboratories,  many  of  which  are  presided 
over  by  men  of  world-wide  reputation,  the  steps  of  whose  doors 
are  worn  in  many  cases  by  cis-Atlantic  students  seeking  the  wis- 
dom of  methods  and  the  virtue  of  inspiration  not  easily  acces- 
sible at  home.    But  there  were  professors  in  Bavarian  v?'      ii 


Teacher  and  SlwknI. 

before  D„  L„th  me    F  u    ^'^"'^  ^^"  ^^'^''^ '^''^'^  ^ 

^'•""i"?  <.f  an  empire  fro    '      .    ■   I  '"''^TI'''^^'  '^'^'  ''"  ^'^« 
land  had  ..thor  thi^.s  to       „,''"'"' ''^  *''«  '-Pl^^  "f"  this 

-".Pio,  the  p,,e„.,.^:;,'^:-:^;:':^;;;^f-,.i.  Stat, 
growth  of  the  nation,  the  wilden  e.s  1  ''''V^l-f-'  the 

as  the  rose,  and  the  evidoncJ    f       V         "'"''"  ^"  ^'^'«'^<^"> 
eve^  side  ahno.  eon:):'- ::,:^:;:^  V""^  '•''''^'T'^  '^'^ 

'« <'-ger  lest: r^r  iz^c^r "'  ""'^'•''  '-^^^^^^^  ^'"- 

the  trne  test  of  vvhieh       t^l  eV    \''"'''' '^^^  ''''^■''"^     Ji^e, 
-oral  standards.     1^    .-e    s  ,^  '"  '''^  '"^«"-'"a'  and 

corroding  influence  of  mamn  o„  'T  T'''  '''''"^''^  '^  '^^ 

^■^ation,  and  eann,  noUdl^^^  ^;::;:::    j;""^  ^>^-  '-es- 
Prule  of  lifj,      ^ve  forget  that  fh  '"^  "^''^  ""''  ^'^^ 

"ation  to  the  u-orld  is',  itl^  t  '  TT""  '*'  '''^  ^'''"^^  <>^"  '"^ 
-'-^-  and  that  wheat  Z^kl^t'  7\  ^'^  '-'-^  '>t>t 
7  '>..t  <iross  in  eompari..:::^!; tStr  "'  ^"1  "^^^^-^>'' 
alone  are  imperishable.     The  km,ll         '•        '"'^^'^^'t^  which 

'eaol.  and  extend  it,  witl'on     :,.° l",  ,"  ff  '  •°'  t*'  '° 
cold   o„d   lifeless;   gerond    a  fill  "-"■"<:'"»'  L-ecoiiie. 

book.  U,t  t,.e  l,V,n,  «:  l' et'd   f^r,  f  ™'  '■- 

wivea  trom  experimental 


i .  -I 


i  J 1  J 


's-Im 


10 


Teacher  and  Student, 


and  practical  work   ii.   the  best  laboratories.     This  {•^w  of 
instructor  is  fctunately  not  rare  in  American  schools.      Tiic 
well-gr<)iiii<lofl  students  who  have  j)nr-iied   their  .-J     i'f-.   in 
England  and  on  the  Coniinent  have  add'xl  deptli  and  breadth 
to  oiu'  professional  schoiar.-liip,  and  tiieir  critical  laculties  hiive 
been  sharpened  to  discern  v/liat  is  be^^t  \i<  the  world  of  medi- 
cine.   Tt  is  particularly  in  t'lcsi'  l)ranch  ■;  tfcat  we  need  teacher? 
of  wide  learning,  whose  standards  of  work  a)<>  the  Lighcst 
known,  and  whos':-  methods  are  ihose  of  tiie  ma;  ters  in  J&rael. 
Third,  men  who  have  a  sense  of  ohlir/ation,  that  feeli^sr  which 
impel.   ;(  teacher  to  be  also  a  contributor,  and   lo  add  to  t!:;, 
stores  iV')in   iviiicli  he  so  '"reely  draws.     And  precisely  here 
is  the  nee "isity  io  know  .'he  best  that  is  tausiht  in  his  branch, 
the  world  u'.'T.     The  investigator  to  be  successful  must  start 
abreast  of  ihb  <now!e(ige  of  the  day,  and  he  differs  from  the 
teach*  r,  who,  living  in  the  present,  expounds  only   what  is 
current,  in  that  his  thoughts  must  be  in  the  future,  tnd  his 
ways  and  n'ork   in   advance  of  the  day  in  wiiich    L  -   lives. 
Thus,  unless  a  bacteriologist  has  studied  methods  thoroughly 
and  is  familiar  with  the  extraordinarily  comidex  flora  associ- 
ated  with  healthy  and  diseased  conditions,  and  keeps  in  touch 
with  every  laboratory  of  research  at  home  and  abroad,  he  M'ill, 
in  attempting  original  work,  find  himself  exploring  ground 
already  well   known,  and  will  probably  burden  an   already 
over-laden  literature  with  faulty  and  crude  observations.     To 
avoid  mistakes  he  must  know  what  is  going  on  in  the  labora- 
tories of  England,  Fran(;e,  and  Germany,  as  well  as  in  those 
of  his  own  country,  and  he  must  receive  and  read  six  or  ten 
journals  devoted  to  the  subject.     The  same  need  for  wide  and 
acciu'ate  study  holds  good  in  all  branches. 

Thoroughly  equipped  laboratories  in  charge  of  men  thoroughly 
equipped  as  teachers  and  investigators  is  the  most  pressing  ioa?d 
to-day  in  the  medical  schools  of  this  country. 

The  teacher  as  a  professor  and  practitioner  of  his  art  is 
more  favored  than  his  brother,  of  whom  I  have  been  speal  ing ; 
he  is  more  common,  too,  and  less  interesting ;  though    '    the 


ni  iwjiiiipjrmB 


Teacher  and  Student.  -.y 

for  .l,e  preven."  ,  a  °™  '„?,''  ''°"" ,"'  '"«''""''  "^  '"  "' 

the Me,',H,pinr„f  r;  'ri ;""" "''° '■»"""'« 

as  the  laboratory  i,i  w|„-,.|,  ,,„  "'»«  tavorcci  ,„  a.,  much 

tant;  i,„K|,e  olumly  k„„„|„|„    '  f    f  I""™*    "to  oloss  co„- 
mei.t  of  the  v„„„.,er  n.e,',,   „        !        '  ,'"  ""=  ^^-'age- 

to  c„«rn„„i  ,0  ;t  It,  L'';':;s  enri-"  ""'^- 

an  illusion  to  a  verv  delioato  n,.,H.      '^^t-'>"t  I  pass  on  with 
171  -   "eiicdte  matter  ui  coUpap  f.i«i,T*: 

-:;rerr;i:::':ir''i~^^^^ 

upon  -he  di^dva,,  „g         'a       od'orr     "  "'""  '""""'<» 
of  mature,  u„t  ,„  ,^,°,,i  „,  °  ;;^°°, °f  ''".;■'"«  to"  '"any  men 

sixth  .l«,les  there  U^,  .o^r    j,  orrZ';  .'f  "T  '"' 

«hertha„to.aurta»:;r.^r'ztr,;:r 


I:i4 


12 


Teachir  and  Student. 


or  later,  to  sonio  oiilv  ton  piiinCiilly  evident,  to  otliers  iincoii- 
scioiisly,  with  no  piiee  perceived.     And  with  most  of  us  this 
physical   ehaniie   lias   its   mental  equivalent,   not   necessarily 
accompanied  hy  loss  of  (lie  powers  oC  application  or  of  judo-- 
nicnt ;  on  the  contrary,  orieii  the  mind  j^rows  clearer  and  the 
memory  more  retentive,  lint  the  change  is  seen  in  a  wealvencd 
receptivity  and  in  an  inaiu'lity  to  ada|)t  oneself  to  an  altered 
intellectual  environment.      It  is  this  loss  of  mental  elasticity 
which  makes  men  ovei"  lorty  s(»  slow  to  receive  new  truths. 
Harvey  complained  in  his  day  that  few  men  above  this  critical 
age  seemed  able  to  a(^<'ept  the  doctrine  of  the  circulation  of  the 
blood,  and  in  our  own  time  it  is  interesting  to  note  how  the 
theory  of  the  baciterial  origin  of  certain  diseases  has  had   as 
other  truths   to   grow  to  aci'eptance   with  the  generation  in 
which  it  was  announced.     Tlie  oidy  safeguard  in  the  teacher 
against  this  lamental)le  condition  is  to  live  in,  and  with  the 
third  decade,  in  company  with  the  younger,  more  receptive, 
and  progressive  minds. 

There  is  no  sadder  jiictiire  than  the  Professor  who  has  out- 
grown his  usefulness,  and,  the  <iuly  one  unconscious  of  the  fact, 
insists,  with  a  praiseworthy  zeal,  upon  the  performance  of  duties 
for  which  the  circumstances  of  the  time  have  rendered  him 
unfit.  When  a  man  nor  wax  nor  iioney  can  bring  home,  he 
should,  in  the  interests  of  an  institution,  be  dissolved  from 
the  hive  to  give  more  laborers  room  ;  though  it  is  not  eve  / 
teacher  who  will  echo  the  sentiment 

"  liiit  HIP  not  live  .... 
After  my  flnmo  liu;kH  oil  lo  ho  the  snufT 
Of  younger  spirits  wiiose  appreliensive  senses 
All  but  new  things  disdain." 

As  we  travel  farther  from  the  Kast  our, salvation  lies  in  keep- 
ing our  faces  towards  the  rising  sun,  and  in  letting  the  fates  drag 
us,  like  Cacus  his  oxen,  backwanis  into  the  cave  of  oblivion. 

And  let  me  conclude  this  portion  of  my  address  with  a  few 
practical  observations.    1 1  is  useless  to  disguise  from  the  public 


Teachei-  and  Student.  jg' 

with  a  population  of  ,hX U   !         „  ^"'■'  '^"; '"  f^  «tat.,  and 
this  twin-citv,  you  c.n  Jo  ^  '"  ""I'' ^^^''t^red  in  and  about 

summation  o  yZv2l,tu  .  "'^  "'"''^'^"^^  ^«  «  -n- 

you  will  require  ft  latr"      "V"^  '"'"'''''^^  ''"^  "'-^ 

i%'tl.enex?t.ent;  V  ;'   f  "siflT  """'--"^^"^^'^^ 
branches  with  the  neresC',.         '''^^"•"fr*"'  '""  thesoientific 
$200,000.    Radiator  f3:r;':  ^^;'  .  ^"^^  -^  ^-  than 
tho  general  lecture  roon       bn  "an  '"^''  "'"■'^''  '""^-'"^ 

Joss  expensive  than  senlto   'n^-,       "'"''"'"'  ''"-^  ^^"»'''  »'e 
versities.     To  provide  ?,  f  "'f'  "''  '"  "'^  «^™«"  Uni- 

who  know  tl,:  Ct  nt      IT         '."  '"^"  ""  '-''-^'— 
will  take,  with  stc   1  f      71'  ""''  '""^'''*  '■"  the  world- 
thousand  doll  r       :  t'l"'  f^'^T  ^-^  -d  five  hundred 
thousand  dollars     ^  "Vhl  l":  V  ?  ,"'  '"'"   ''''''  ^"  «- 
proportion,  and  in  moLn  o,  e  a Z         ''"'"'""^  '""■^*  '^  ^ 
wards  and  clinical  laboratoZ         f  ''"'"''  ^'J^^''^^^"  P^^i'-on 
dollars  may  be  spent      A^     17    ,"  '7'  '"'"'*"^'  *'^«"«-"d 
of  the  equi^,n,en    o    a  firs   di"  "V^''"*  ^^''"''^  '^^  ^'^  -«t. 
of  a  kind  sLch  as  exists  in  ht^'  ""'f^'^^^^^--^^  school,  one 
one  of  which  woulc.  g    i  ",'      J  '^Z  «--"  towns,  (any 
one  n„-llion  dollars-Lt  1  s«  ^nd  ^  "''?^'  ^  ^^""'^^  «^^ 

Where  now  shall  we  \Tl  7    '^      ''''  ^  ^'"^«  "^of«- 

Can  wereasorablyL;^  i^^^^  '!;•",'  -^—'ts. 

coimtrv  ?    Yes  the  flofv^'l  ,     '  ""'^"^^  «^'^oo's  of  this    . 

Theology,  i,s  wi'tl's  "7  'fs  a  llv^-;'^'!  ^'^^.^'•^--'  -th 
snj'port  has  not  paralyzed   '^  V"   f''""  ^''''  '^'^'  «*-*« 
of  your  wealthy  men  C  Lf/    '      ^^^"f ««-«.  and  that  some 
blessedness  ofgivJng     Zm,       "^  '^1  P'^^«"'-^«  of  life  the 
onlv  wav  to  perperuaie  !  n^      ^  T''  ^'"'■"  *''^  ^^^-^^t  of  the 
are  not  heredS;, Id  il  istt '"     "  ."""^^'^  '   ^'^^^-^-'"^ 
stand  the  pace  litV^r^::Z^^-^^^^ 
danger,  too,  that  in  the  Democracy  Jihe  2      V  ''™'' 
average  will   be  so  high  that  lul       ^'''f"*"''«  the  general 

chosen  few,  a  poet  :.4e  and  tl^       ^  k"  '""  '""^^  ^"  ^ut  a 
P       ...re  and  there,  'born  for  the  Universe' 


w 


14 


Tt'acher      id  Student. 


and  the  cnnitallstn,  wliu,  likr  JoIiuh  Hoj)kins  and  Cornell, 
have  linkc'l  their  names  with  tiie  imperisluible  things  — 
names  which  in  the  centuries  to  conu'  may  attain  the  sweet 
savor  of  -aiictity  wiiicli  to  day  lingers  on  the  tongue  as  we 
utter  the  words  Harvard  and  ^^>' 

III. 

Students  of  Medicine,  Children  of  the  Guild,  with  whom 
aie  the  promises,  and  in  whom  centre  our  hopes — let  me  con- 
griitulate  you  on  the  choice  of  a  calling  which  offers  a  com- 
bination of  intellectual  and  moral  interests  found  in  no  other 
profession,  and  not  met  with  at  all  in  the  common  pursuits  of 
life — a  combination  which,  in  the  words  of  Sir  James  Paget, 
"offers  the  most  complete  and  cmstant  union  of  those  three 
qualities  which  have  the  greatest  harm  for  pure  and  active 
minds — novelty,  utility,  and  chanty."  But  I  'un  not  here 
to  laud  our  profession ;  your  presence  on  these  benches  is  a 
guarantee  that  such  praise  is  superfluouh.  Rather  allow  me, 
in  the  time  remaining  at  my  disposal,  to  talk  d"  the  fiictors 
which  may  make  yt)U  good  students — now  in  the  days  of  your 
pupilage,  and  hereafter  when  you  enter  upon  the  more  serious 
studies  in  whiiii  the  physiciaii  finds  himself  engaged. 

In  the  first  place  acquire  early  the  Art  of  JMachmcnf,  by 
which  I  mean  the  faculty  of  isol  ting  yourselves  from  the 
pursuits  and  pi> :isnres  in>ident  t(  youth.  J'v  nature  man  is 
the  incarnatiiin  of  idleness,  which  quality  alone,  amid  the 
ruined  remnants  of  Edeinc  characters,  reniains  in  all  its 
primitive  intensity.  iJccasionally  wo  do  find  ;;.  individual 
who  takes  to  toil  as  others  to  pleasure,  but  the  majority  of  us 
have  to  wrestle  hard  with  the  original  \''!im,  and  find  it  no 
easy  matter  to  scorn  delights  'ind  .ve  laborious  days.  Of 
special  importance  is  this  gil  thosi  of  you  who  reside  for 
the  first  time  in  a  large  cit\  ;  i  ly  attractions  o.  -  lich 
offer   a  serious   obstacle   to  actjiw-ition.     The  diM'ipline 

uecessary  to  secure  this  art  brings  in  its  train  habits  (  '  self- 


1 


Teacher  and  Student. 


15 

:;::;i::"„n;'j°™' ' '« ""■-■"-« -. ...» .,«,„. 

bntifv..,,,!     l-t  ,3  ;,,'";■'« '" '""  »"^<<"  ;i".v,: 

-^rWdW,   ,1,0   lr,nL  '  :i     ?''""  "''™  ".ll»   I ■"■'»« 

» 0  e«. ,i   ;    rr  "    ■;""-  "■"*.  "'"-I'  -  to 

»t"<ly  I.V  a  ,cl,Iic  i     1     i"    '  ,'°  »"PI'l™'™t  i"  private 

bwomeat  la,t  cuL'r-ii,,,^     ,,7  '  .  ''  ''"•''  V" ™y 

"'-    .«i  of  a  J;,"'!;"  f  V    ,,^  r'  f '"""'"  """"■'■  ""'I  »' 
l-.,el,  ft,.  i„  ,:,v;ee  „f       '  1 ,"'"''";""  "''"''^  "'"•^  «"<• 

-«/: ..."  «.  .:r:Lt  px;.,:  ra"":^  "'■•""■"^:- 

now  in  the  t,   io  of  vm...  .,..  i    I-      f   ^'^'"'^'^  ^'^  this  virtue  is 

demands  „no„  a  b.i.v  loo  oT    ^  .    ^''^"'"'''^^^'"tand  irregular 

but  the  public  in    his  n  t  /'  '"'^  ^^■■^'^"'t  <"  •-«*«>•", 

whopra  tis^iith       L      n'tr'"  '"r''"=^^"''''"^  ^'-  "- 
to  certain  wori<     c^;     ":;   "'''"^  '  ^^'«'»»^^  ^--  of  th..  d. 

a  little  leisure.  Hie'     \         '""'" '"^'"^  '^ave  at  any  rate 

"p;v;;uheda.::;:;^::i;:::-;:-^^^ 

and   the,r  patient  .      fn   o„e   respee       1    ,  ""^'■''''■'' 

Phy.^ician  is  absohueiy  oriinin- 1       R     1  '  ""^^^ternatio 

traries  there  is  sure  to  be  .  .^[    ^"  ^'''''  '^^"'  "^'  ^'O"" 

crcaturo  to  who"  ffl"'       '""  '?  ^^''^  ^«"'^'  ^^^'^ 

rendered  miserable  b,  ;,;e  :L       ,  r  ;:=';;-''-  li^i« 

a       -.  "»  a  man,  tlie  uiiimg-room 


,1  J 


I    111 


16 


Teacher  and  Studnii, 


table  in  wliose  house  is  never  "elenmi,"  luul  who  would  un 
he  could  "bnuldiist  at  live  o'clock  tea  and  dine  on  the 
followiiiij!;  day." 

Tile  otiiiT  as|H>ct  of  nu'thixl  has  a  deeper  significnuw,  liard 
for  you  to  roach,  not  consoiinjx  when  attained,  since  it  lays 
bare  our  weaivneHHCH.     The  pract  ico  of  ■   .(licino  is  an  art,  l)aHed 
on  science,     Workin-,^  in  science,  witli  stiieiicc,  for  Hcicncc,  it 
has  not  rcaciied,  pcrhapn  never  will,  the  dignity  of  a  complete 
science  like  astronomy  or  cngineerin^f,  with  exact  laws.     Is 
there  then  no  scieii.'c  of  medicine?     Ych,  but  in  parts  only, 
.such   as   anatomy   and    physiohtgy,   and    the   extraordinary 
development  of  these  brandies  during   the   present  century 
has  been  due  to  (he  cultivation  of  method,  by  which  we  have 
reached   some  dej^ree  of  exactness,  some  certainty  of  truth. 
Thus  we  can  weigh  the  secretions  in  the  balance  and  measure 
the  work  of  the  heart  in  foot-pounds.     The  deep  secrets  of 
generation  have  been  revealed  and  the  .sesame  of  evolution 
has  given  us  liiiry  tales  of  science  more  enchanting  than  the 
Arabian  Nights  entertainment.     With  this  great  increase  in 
our  knowledge  of  the  laws  governing  the  processes  of  life, 
lias  been  a  corresponding,  not  less  remarkable,  advance  in  all 
that  relates  to  life  in  disorder,  that  is,  disease.     The  myst(!ries 
of  heredity  are  less  mysterious,  the  operating  room  has  been 
twice  over  robbed  of  its  terrors ;  the  laws  of  epidemics  are 
known,  and  the;  miracle  of  the  threshing  floor  of  Araunah, 
the  Jel)usite,  may  be  repeated  in  any  town  out  of  I3und)le(lom. 
All  this  change  has  come  about  by  the  obsei'vation  of  facts, 
by  their  cla.ssilication,  and   by  the  founding  upon  them  of 
general  laws.     Einula^iug  the  persistence  and  care  of  Darwin 
we  must  collect  facts  with  open-minded  watchfulness,  unbiassed 
bv  crotchets  or  notions;    fact  on  fact,  instance  on  in.stance, 
experiment  on  experiment,  facts  which  fitly  joined  together 
by  some  master  who  grasps  the  idea  of  their  relation.ship  may 
establish  a  general  princij)le.     But  in  the  practice  of  medi- 
cine, where  our  strength  should  be  lies  our  great  weakness. 
Our  study  is  man,  as  the  subject  of  accidents  and  diseases. 


Were 

insteac 

tion  ai 

this  ill 

only  HI 

are  so 

of  read 

stautly 

rut  of  0 

And 

Thoroui 

thought 

tuuately 

you  as  s 

but  all  ( 

become  I 

wJjat  it 

n])on  wh 

ology~ii 

not  witJi 

principle!; 

fajuiliar  v 

are  made, 

masters  h 

therein. 

tioning  of 

a  degree  o; 

life  duties. 

the  emerge 

that  you  ar 

You  canno 

the  details  ( 

nize  and  si 

mastered   cc 

thoroughneg 

jS^apoleon,  £ 

2 


Teacher  and  Student.  ,7 

^'"•«  I'uve  reac.h  some  t     '  ?       ',"'  [''''"'''  '''  should  ore 
o"l>-  ".-o  the  n.a<..^;^^^',     ■'::'!'-/"'<••''•  art.     And  not 

stantly  ,„i«]c.,|  Uy  tf.e  ,aso  wif  "'^^'''vat.ons,  a,,,!  o„n- 

"'t  "^'o'-o  or  twoox",;,-!:::  '  ""■  '"'"'■'^  ^"^'  '-"^^  ^he 

thoughtof-nmkingitthoonlvsM  1    /  ■''"'■'"'''^   ^''"^   ^   ''ad 

you  as  students  can  hope  to  ot     n  '■"''•'^"Imn,  few  of 

•>"t  all  can  learn  its  va hie  now  "7-  '''""  "  "'^"-"''^  <>f  it, 
'-".o,ivin,exan,>h:':  ^::;:;  "';;-'^''^-itlM>atience 
^viiat  it  ,neans.  A  knowledge  u.,;  T  ""  >'^'"  ^•''^^ 
upon  whieh  our  art  is  based -c I  i  ^""^;""-^«'  --noes 
ology-not  a  snmttenW  h„t  7  '' .T'"^' "'''' !'''>'«'- 
no.  with  all  the  ihets  H  ,t  i!  '  •?',"'  ''"''*  ae.i„ai„tance, 

PWuoiples  l,a«ed  npu ^J^  Y  ^I     ?  '"'  "'*''  ^''^  ^^^^ 

'a...iliar  with  the  metho.     bv  w  '  "'  '''''^''''''  '^^««'n« 

-e  .nade,  and  in  the  SuXt^  ^T  ",  'T'^''^^ 
masters  have  trod.lon    tho.u/ T  ^  "'"'""  ^''«  g'-<^at 

*'-roin.  Witha,oodi^^:  i^;V"-''"'"''^.  ""^^  ^'^ 
tioning  of  time  you  can  ,^ae  '  ,  T^  "  ^'"'  'P^'''' 
a  degree  of  accuracy  w  e  t  ho  "'  "''  "■"""^'"'  ■^^''^'es 
''f«  duties.  It  n^eans  .^h  a  ^o  TV"'"^"''^'"^  ^"'-  ^«"r 
the  emergencies  of  lite  a  d  of  1 1  "H  '^  '^'''''''  '^"^  of 
ti^at  you  are  safe  an,  r  tworti  '"T"^'"'  *''"'^  '-^"^^'^^'"n^ 
You  cannot  of  co„r  e  rt"  b  j^^^^  ^"T  >'-"•  ^^>''o-n.en: 

the  details  of  the  variou  b  a  2^^  ^  "^  ""l'''«S^^  -  g-sp 
"-  and  successfully  treat  7Z^  Cr  T'  "^"^'- 
mastored   certain   p4.cinles   i.  !;  ^"''  '^ >«"  '^ave 

tI.oroughness-you^  il    avoiJ  /      7  T   "'^    ^«"^«^   ^^ 
Napoleon,  according   t     S.hl  t       '^'"  '!'  ^'-•'-^-•-• 
2  ^        ^'^'"*'  ^'"^^'>  o"e  day  said  when 


;  L 


18 


Teacher  and  Student. 


somebodv  was  spoken   of  in   his   presence   as   a  charlatan 
"Charlatan  as  .nuch  as  you  please  but  where  is  there  not 
(.Imrhitanism  '^  "     Now  thoroughness  is  the  sole  preventive  of 
this  widesprea.l  malady,  which  in  medicine  is  not  met  sv.th 
only  outside  of  the  profession.     Matthew  Arnold,  who  quotes 
the  above  from  Salute  lieuve,  defines  charlatanism  as  the 
"confusin..-  or  obliteratinj?  the  distinctions  between  excellent 
and  inferior,  sound  and  unsound  or  only  half  sound,  true  and 
untrue  or  onlv  half  true."     Tlie  hi-her  the  standard  of  educa- 
tion in  a  profession  the  less  marked  will  be  the  charlatanism 
whereas  no  trreater  incentive  to  its  development  can  be  found 
than  in  <cn(fing  out  from  our  colleges  men  who  have  not  had 
mental  training  sufficient  to  enable  them  to  judge  between  the 
excellent  and  the  inferior,  the  soind  and  the  unsound,  the  true 
and  the  half  true.     And  ii'  we  of  the  household  are  not  free 
from  the  seductions  of  this  vice,  what  of  the  people  among 
whom  we  work  ?     From  the  days  of  the  sage  of  Endor,  even 
the  rulers  have  loved  to  dabble  in  it,  while  the  public  of  all 
a<^es  have  ever  revelled  in  its  methods— to-day,  as  in  the  time 
of  the  Father  of  iMedicine,  one  of  whose  contemporaries  (Plato) 
thus  sket^-hes  this  world-old  trait;  "And  what  a  delightful 
lifi.  tiiey  lead  !  they  are  always  doctoring  and  increasing  and 
comi.licatlng  tiieir  disorders  and  always  fivncying  that  they  will 
be  cured  by  any  nostrum  which  anybody  advises  them  to  try." 
The  Art  of  Detachment,  the  Virtue  of  Method,  md  the 
Quality  of  'riioroughness  may  make  you  students,  in  tlie  true 
seiijje  of  the  word,  successful   practitioners,  or  even  great 
investigators;  but  your  characters  may  still  lack  that  which 
can  alone  give  permanence  to  jiowers— the  Grace  of  Humility. 
As  the  divine  Italian  at  the  v.ery  entrance  to  Purgatory  was 
led  by  his  gentle  .Master  to  the  banks  of  the  island  and  girt 
with  a  ruslC  indicating  thereby  that  he  had  cast  off  all  pride 
and  self-conceit,  and  was  thus  prepared  for  his  perilous  ascent 
to  the  realms  above,  so  should  you,  now  at  the  outset  of  your 
journey  take  the  reed  of  iiumility  in  your  hands,  in  token 
that  you  appreciate  the  length  of  the  way,  the  difficulties  to 


Teacher  and  Student.  jg 

oneself  ,,„  „i,li.s,„,"     r,"  *""  '"  "'"'"=  "'«  "><>"  "f 

■'.•il.cN  a,„l  r,„.  ,i,o  .„i  „/,,?■?  ',""'"  '■•"■  '■'•'  ""'n 

*..„:.■  ,.u  .„„  ,„.„  „n,:  ,  i :","?:;  "■- -  :!■■"  "-■"iy 

since  with  it  comes  not  n»Iv  n  '''^  '*'''  °^"  sake, 

proper  estinu.tio;  f  e^il:;:;!:'"'"  '^"-  ^''"^'''  '>"^  '^'-  a 
for  it  More  perhaps  fl.""'"""'"'''-'*^  "'  «"r  search 
doctor  has  a  c„  •  !!,  '  /!^;''"\  7/-"-'^'  "-",  the 
H-at  he  regards)  pers^t^'LL^  ^  i'  7-"'^^?'^^^  ^« 
It  IS  too  often  accompanied  bvn  ,^J  ^^      '  "  "^''*'  ''"* 

a  Johnsonian  wor<l)^v  c  if  '"'^"■"'•^r'*"'  "^  •^I"'"'"""  (^«  "«e 
conceit  that  the  nliiil  ^^^  ^3:;^^  '  ^^^  ''  ''  ^'^^'^  ^ 
stances  is  regarded  as  a Ch    •?•  f  '  ""•'^■^' '''"^  ^'''^»'"- 

-l-'"y  resen^^d  .h  h  r  of  r:: j-''^  'T'-  '  ''''''^^ 
Start  out  with  the  convicf.n.         .     ,         l"'^»^^'^'^=o"al   origin. 

diseased,  that  slips  in  observ"  on  "'"'"•'";■"'  '"*'^'*'^>'  - 
t'H'  I'ost  trained  facwltie      h\V  '"'"^"''''^  ^^''^^  ^^'"t'l 

i"  the  practice  Ja  ^f^V"""' ^  ^"''^"^^"^  "".st  occur 
probabilities  ;-^LV^vt!;'  ^'^'^^'^  ^'^  •^^'--"g  of 

-^ifakeswiHbcacLi:sc  „  ;r;;::^^f-'^ 

a  slow  process  of  self-deceptk)n  with  1,     '    '  '"''''"'  "^ 

to  recognize  truth    you  wi  I    ,         J    ''"'"""'^^'^'^^'''ff '^ability 

lossons'which  nu.y    :  b     vo    ?"     "r  T"  "''""''^  ''^  ^^^ 

.And..rthesaL:;::Ln;;:-  -r;fn  r 
Fftious,the.ud:;;:.:^^::;::;^-^^^^^^^ 

and  you  will,  to  use  the  quaint  Jangu.  e      Si   ^T    "''  ^"''"'''' 

allow  one  o^e  for  wh2t  is  laud^dd  t   ^  .''"ll^lf  "^"^' 

l'"g  and  nnscemly  disputes  which  Iriv,  a  ^''^  wrang- 

our  profession  arise  in  u  groamioitv    f"       "'  ^''■^^^™^^^^ 

gicat  majonty  of  cases,  on  the  one 


i|     I 


i 
1 

_, 

I; 
1  t 

!   ■ 
i    i 

i   '; 

i     ■ 

i 

1 

' 

1; 

1^. 

»!-        t 

L 

20 


Teacher  and  Shident. 


hand,  from  this  morbid  sensitiveness  to  the  confession  of  error, 
and  on  the  oihor,  from  a  lack  of  brotherly  consideration,  and 
a  convenient  forgetfiilncss  of  our  own  flulings.  Take  to  heart 
the  words  of  the  son  of  Sirach,  winged  words  to  the  sensitive 
souls  of  the  sons  oi'  Ks(MiIai)iii~  "  Admonish  a  friend,  it  may 
be  he  has  not  done  it;  and  if  lie  have  done  it,  that  he  do  it 
no  more.  Admonish  thy  friend,  it  may  be  he  hath  not  said 
it;  and  if  he  li;;ve,  that  lie  speak  if 'again.  Admonish  a 
friend,  for  many  times  it  is  a  sland'er,  and  believe  not 
/"  every  tale."  Yes,  many  times  it  is  a  slander  and  believe 
not  every  tale. 

The  truth  that  lowliness  is  young  ambition's  ladder  is  hard 
to  grasp,  and  when  accepted  harder  to  maintain.  It  is  so  dif- 
ficult to  be  still  amidst  bustle,  to  be  qui.t  amidst  noise;  yet, 
"  es  bildet  ein  Talent  sicli  in  der  Stille  "  alone,  in  the  calm 
life  necessary  to  continuous  work  for  a  liigh  purpose.  The 
spirit  abroad  at  present  in  this  country  is  not  favorable  to 
this  Teutonic  view,,  which  galls  the  quick  apprehension  and 
dampens  the  enthusiasm  of  the  young  American.  All  the 
same,  it  Is  true  and  irksome  at  first  though  the  discipline  may 
be,  there  will  come  a  time  when  !ie  very  fetters  in  which  you 
chafed  shall  be  a  strong  defence  and  your  chains  a  robe  of 
J  glory. 

Sitting  in  Lincoln  Cathedral  and  gazing  lit  one  of  the 
loveliest  of  liuman  works,  as  the  Angel  Choir  has  been 
descrilied,  there  arose  within  me,  obliterating  for  the  moment 
the  thousand  heraldries  and  twilight  saints  and  dim  enil)lazon- 
ings,  a  strong  sense  jf  reverence  for  the  minds  which  had  con- 
ceived and  the  hands  which  had  executed  such  things  of 
beauty.  What  manner  of  men  were  they  who  could,  in  those 
(to  us)  dark  days,  build  such  transcendent  monuuients  ?  What 
was  the  secret  of  their  art  ?  By  what  s])irit  were  they  moved  ? 
Absorbed  in  thought  I  did  not  hear  the  beginning  of  the 
music,  and  then  as  a  response  to  my  reverie  and  arousing  me 
from  it,  rang  out  clear  the  voice  of  the  boy  leading  the  anti- 


Teacher  and  Student. 


tl'o  outward  an.     "n^r  lirf  ^'^^/•"  ^^'"^  "^"t 

them.  ^''  ''^"'  «^  ^^^  >>JeaIs  which  animated 

before  in  the  world's      1         ''      ^"^'^'  '"'''  ^^  '''-^1^1'^"^^ 

weakened  the    nt    L  "of  ile'T       7'^ '  ^"^^^"'^  '-« 

^Jiffevenee  between  n^Lldt?'   8,,,  '  "^  ,^^  ^^-"^' 

^^leal  Life,  the  ideal  Churcl,--wl  L  tf   '  .'"'  ^^*"^^'  ^^'« 

realize  them-snch  dreamTo     I       ^'^'^  «••«  ^"^  ^ow  best  to 

-en,  and  who  can  d     b  TL  ttl    ""  '"  ''"'"*  '^'  -'-'«  ^^ 

^-.■s  the  npward  ^^^^^ Z:rt:T  ^'""^-^^'^ 

fession,  have  cherished  «fnn,i    a  ^'  ^°^'  ^'^  »  Pi'o- 

portray.  -^  suDject,  I  have  attempted  to 

bound.     The  choice  it  "If      ^""^  ^"'"'^  '^  indissolubly 
Always  seelc  your  ^^^  "  Et,!;t  ^VjJ^^  ^^^^  yo^ 
call.ng  a  sordid  business,  regard  Z r  n  1       ^     '"'^  '""'''"^ 
many  tools  of  trade  and  [f^T    ^         ^^"«^^  ^^^-eaturos  as  so 
-ay  be  yours;  bu  '  ^^  W      f     'T  ^'"''  '^^''''■^'^  ^'-^^'^^  ^^^3^ 
right  of  a  nobe     ert.'e      n        !  ^7''''''^  ^''^y  «^«  birth- 
tbe  physician     s    1      Frlnd  If"^    '"  well-deserved  title  of 
traditions  of  an  aXftZdu/      m  '  n"'  '^'^''^*^  ^'>«  best 
band  r  have  tried  r  if  :;f^^^  On  the  other 

-ay  reasonably  cherish  N„  "1  /''  l'^''^'  ^^^'''^h  you 
toxical  in  conirilo  with  th.  ?-■  '^'°"^''  ^'^^^  '''  P^^a- 
you  work,  they\  ;;f  ft  "7  '""'^'^''^"^  '"  ^''•«h 


l,;i^     »S 


f.li    I 


I  irA 


22 


Teacher  and  Student. 


renown,  consistently  followed  it  will  at  any  rate  give  to  your 
youth  an  exhilarating  zml  and  a  cheerfulness  which  will 
enable  you  to  surmount  all  obstacles— to  your  niaturity  a 
serene  judgment  of  men  and  things,  and  that  broad  charity 
without  which  nil  else  is  naught— to  your  old  age  that  greatest 
of  all  blessings,  peace  of  mind,  a  realization,  maybe,  of  the 
prayer  of  SiKTates  for  beauty  in  the  inward  soul  and  for 
unity  of  the  outer  and  the  inner  man  ;  a  fulfilment,  perhaps, 
of  the  promise  of  St.  Bernard,  "pax  sine  crvniine,  pax  sine  tur- 
bine, pax  sine  rixa." 


)ur 

'ill 

a 

ity 

est 
he 
'or 

sr- 


ir;ji  11 


I'KOKESSOR  OK 


THE  AM 


Cxx\V 


Tuberculous  Pericarditis. 


BY 


■-o.«=s„. ,  Z^„'.^^.^^S;,„^.°;- -^i^^---  ^o™., 


HOPKINS  UNIVERSITV  A  Mr>  „. 
™  THE  JOHNS  HOPKINS  HOSPITAL       '"'"'="^'^-"*-^^H.a. 


THE  AMERICAN  JOURNAL  OF  THE  MEnrr., 

iHH  MEDrCAJL  SCIENCES. 
January,  1893.  • 


s' 


Irs: 


r 


i: 


i„:.:   ii     1 


'■M 


w 


,:  * 


I    'i 


K.vtr; 


I'/ioKi-: 


Tf.uci 
fiudiii.s. 

WeiC  iDiK 

tiiherciilo 
relative  i] 

Hoj)kijis 

Of  late  y, 

''fiH'o,  aiul 

tlie    y^rfer 

M'''/ieu.s  *t( 

i'atlio]()gi(v 

'I'lie  foil, 

"ly  ohserva 


<'a'^k  I.~ 

f'xiidato  in  i 

Cask  11.. 

exiidaie;  m 

ami  iiiediasi 

Ca.sk  III. 

'ii'>ercij]().^i,s' 

Ca.sk  IV.' 

'litis-  acute  i 

Cask  V.- 

'■eceiit  tul)ero 

Cask  \7.- 

I().sis;  cluMiiic 

Cask  Vli 

'iiiK'fciilo.sis  • 

„Cask  viii 

'"•ro-caseoiLs  ( 
rhn^ic  serum  i 

aljscess;  tiiben 
PL'ricanlitis. 


l''Stnvtv,\  r|..„„  Tl„.  A 


iiiciicjiM  ,;, 


''•''  "'■""•  ■\rc(lic..,l  s,. 


''■'"■'■S-'niiii;irv,  lyr.',. 


■>>mwi:wvs  pi:i,,cu:i,iTis 


r/s. 


I'liiii-/:.. 


'!v  Wll./j 


■I'  Ari:i.|.  , 


'1 


'f-nKiicfLosis  ibJJ„ws  iK.nl 


canliiis.     Tiie  nil 
.sonic  cases  anat 


'('(■tiiiii 


Is   IISII, 


"l""i  i'lieuinati\'  f 


iilly  (ivcrj,,,,), 


"'^'fo  made 


"imcally.     J„    i,„„) 


kod  clii 


L'ver  a.s  a  cause  of 


tiiI)erciiJ(.iis  I 
relative  1 


'    (iH'.Mnlil 


'fsion.s  ill  7  oi   wl.icl 


I'cal  (ieiieral  JI, 


aiilo 


t».<ie.- 


■^pital,  tl 


".'■'^^""y,  and  ,,os.sil,| 
""'   '"".i'-rily  „i'  nl'iicli 


III 


JICll- 

y  in 


;'^';i""i>cyniayl,c.ail.,,„,, 


'  "'i'  |icricardii,„ 


':^'''^'  ^^'•'■^'  :^7o  eases  with 


Hojikins  H, 


'•■:  'y^'"nl.s  af   tl.e  Pathol 


''"'"  the  foil, 


Of  I 


iUe  V 


<l)it 


Of 


'cal   Lahorat 


"   \vas  iiivoJve.J.     Jfs 
y  'i;,^iires,  furnished 


)\VlIlcr   ( 


J'ence,  and  y^^t  tl 


wirs  attention   I 


'"Stances  oi  pericarditis,  6 
lias    liocii    r.,  ,i.,,i  ,     . , 


'"■y  "f  the  Jol 


hns 


ic  re( 


J/'W/ 


llith 


"'■<'--^  "1  the  literal 
'".'/"'■   contains   only  tl 


'<-^^'"   called  to  the  i 


Hfre  tiiherciil 


"'■t'  are  not  very 


'•'•'liH-ncy  of  its 


'"■"•■  t<'  -fnly,  1^2,  o„l 


J'athological  S 


y  tnen 


lurty  I'efer 


nnnie 


'Oils 


ioiis. 
oceiir- 
tl 


'UI.S, 


ty-sev 


en. 


•^'"cos,   an.l    the   /,,,/,, 


lio  follow 


-^•'.^>tV;'^  London  include  l.ut'h- 


The   7 


''(imivt! 


my  ol)ser\-atioii  i,,  ^ 


'"K  is  a  briel  siini 


ve  cases  to  date 


oiiH  of  the 


,'"«'y  of  the  eases  which  I 


<'asi.:  r.__j, 


'""■"'•'    '^''"'"Wphia,  and  I 


lave  c 


'xudate 


"eiiiah 


>altimor(. 


'"me  luiiler 


111  pericardiiii, 


ex  IK 

an( 


Casic  n.-]yia| 
i'ate;  miji 


le,  aL''ci 


i'.ired   fortv-tl 
I  mil 


^reiiera 


'iree   ^■ 


■ears ; 


'  med 
Casio  Ilf.— j 


lasiiiial 


ary  tiioer 


hv 


e  vear.- 


"«'T  tul)erciil.,si 


sixteen  ounces  of  ,la,k 


fiiltercul 

(' 
ditis 


laih 
'einah 


•cles  on  the 
easeous. 


easeoiis   m 


peritoneimi  and 


i'sses  and  fresh   viil 


oil; 


As 


<';'s;  fresli  tiihcculous 


aj?ed    thirty-ei.rl, 


'"  '"'i^s;   bronrhial 


•:  IV.-M 


elite  tuhercu 


ii't",  aged  sixtv-fi 


pericarditis, 


t    ve 


irs , 


cl: 


"■""ie    pulmonary 


Cask  v.— ]\lai 


•I's  ph'urisy;  chr 


"";  yt'ai's;  acute  tiil 


leceiit  tuhercul: 


aged   fift 


Cask  \'r.--M; 


l''"s  pericar.litis 


y  years;  chr 


■•""'e  pulnion, 


•ercuL 


'onic 


piilm 


iry  tiiberciii 


)us  pericai 


w.ia. 


osis 


lie 


c'lronic  tiihercul 


li^ed  i\ 


'I'tv-five  ve: 


'""ary  tuberculosis' 


tubi 


ASK  Vll.-Mal 


ous  pericardit"is 


urs;  cl 


lerculosis;  tul 


Cask  VlII— 3[, 


•ercii 


<-',    aged     f 


"•""ie  I'ulnK.nary  till 


>ercii- 


OMS  o 


weiity-eight    years;    d, 


iiiv  JJ. 


'f  J)leu 


'•'i;  acute  tubercul 


roiiic 


pulnionarv 
■      -.ii 


fihro-casemis  ^ilT;^'""'''  ^^'  ''"^^  tl'irtv-si7;;;;:;':^';"r"  l^'f ^nrditis. 


aoscess;  tubercul^ 
pericarditis. 


""s  iiifiltrat 


iged     fifty 


Kui  of  parietal  I 


years;    tuberci' 


ivcr 


ei'  ous   mediastinal 


'"  pel    ard 


""" ;  acute 


>'I* 


ii! 


; 


/*, 


I 


il 

1      1 

i 

1 

1: 

■  '1 

*      ^ 

,iSLKK 


■1  V  H  !•;  K e'  U I. O  L' S    1'  K  l<  1 1'  A  li  I ' IT  1  rt  , 


Cnsk  X.-M.IX  S..  n«o.l  torty-Hve  ve..r.  :  l.rinmry  tnl...Tul.)sis  of 
hu^^■eh■,  d.roni.  tuluMTuhus  iKTi.'anl.tiH.  ll...  nu.,nl.ni.u.s  tn-.u  tluee  m 
four  lines  ill  tliidviu'ss:  lii'orirhial  ^rlaii.ls  cii-cou.-. 

Cv  X  .-M>.le.  a^-l  --"ty  two  vearn :  .leal),  h-om  ,..unnn.,n.a: 
lK.a;  hm  tn.plm.l;  ..cri-'anii-nn  a-llHTont.  jrmUly  ti.Hke.R.a  .iml 
tuillMTnliils;    cll'.iru;ti!.n  ol' hrouchial  .^lan.i.  ;    no  ntluT  tul.erde.  .n 

'""(''\'<r  XII  -.lohn  'P.,  awl  sixteen  years;  tnberculous  ccrel)ro-«i.inal 
rneninjr'iti.;    iulnMruiosi^  of  mediastinal  glancla ;    oUl  tubcroulous  i>.'n- 

""rlsK  Xni.--Moses  B.aKi-l  Uvvnty-f mr  >Tars;  tnia.m.lo.is  of  n.e- 
(liaHtinaU'lamls:  chronic  Hil-onuilous  pcncanhtis;  .liiatatK.n  ol  iu  art ; 

a  few  inl)ri(lc!^  in  ]iiii<.'.  ,  .     ,  i  „ 

Cv^K  XIV.-Wmi.  11.  T.,a^re.iiiftytw.  years;  .Irop.v;  I.v|.ertroi,  hy 

a„,r,lii'atation  of  l.cart ;  elinmic  ti.iHmilons  pencanlitis ;  til)roi<l  tu- 
bercles in  lunL's;  niiliarv  tiibercii^.-  in  viscera. 

risr  XV--.r.,lni  I'.ia-ed  tiiirtv-ei-l.t  year.;  .In.p.sy  aii.l  .  lyspn.ea ; 
tuberculous  peiicanlitis  with  eflusion  ;  tuberculous  pleurisy;  old  h.ei  iii 

'"cUsf  XVI.-lvnnia  H.,  eolorcl,  a-d  thirty-nine  years;  dyspiuea, 
coudi,  and  ana-area:  tuberculous  pericarditis,  with  cibi^ion  ;  tu  .ercu- 
l.Jis  of  mediastinal  and  bronchial  ^dands;  scattered  tubercles  in  lun-, 

^'T^'sf^VjT-  -)..hn  ('..  ajred  sixtv-five  years,  admitted  with  coukIi, 
fever'  and  si,  :i.^  »•  ...onsolidatioii  at  left  base.  Death  on  secon.l  day 
■ifter'adnii-''.'  Ciironic  pulmonary  tuberculosis;  fresh  tuberculous 
'pncumoni:.;  ar...  ri.  j-clerosis ;  patch  of  recent  tuberculous  pericarditis. 

Ivrioi.oLiv.—  -'nhercuhnis  pericarditis  is  not  limited  to  any  aj,re.  The 
youngest  of  mv  cases  was  a  child  of  live  years;  the  oldest  a  man  of 
seveuVl«'>  veiirs.  Parrot,  Duckworth,  Rolloton  and  Letulle  have  re- 
ported" cases  "in  infants  under  a  year.  In  liraekmann's  Gottingen  Thesis, 
of  (>.")  eases  collected  from  the  literature  19  were  iu  children.  It  does 
not  seem  to  be  at  all  uncommon  in  old  men,  and  there  are  two  cases  on 
record  in  octogenarians.  Males  seem  more  prone  to  the  disease  than 
females;  there  were  only  four  women  on  my  list. 

Tuberculous  pericatdilis  is  due  iu  a  majority  of  instaiiees  to  infection 
of  the  membrane  from  caseous  mediastinal  lynildi  glands.  The  disease 
may  be  conllned  to  these  glands  and  to  the  pericardium;  thus,  iu 
Case  XI.  of  my  series,  the  patient,  an  old  man,  aged  seventy-two  years, 
died  of  pneumonia  after  a  short  illne.ss.  There  was  no  tuberculosis  of 
the  lungs  or  other  viscera;  the  pericardium  was  thickened,  both  layers 
adherent,  and  presented  cheesy  masses  and  gray  nodules.  The  heart 
was  enlarged,  weighing  seventeen  ounces.  The  mediastinal  glands  were 
calcified,  particularly  the  bronchial  group.  Case  IX.  is  of  special  in- 
terest, showing  the  mode  of  extension  from  the  anterior  mediastinum  to 
the  pericardium.  The  patient,  a  man  aged  lifty  years,  had  pulmonary 
tuberculosis,  and  died  of  acute  tuberculous  pleurisy  with  sero-puruleiu 
exudate.     Upon  the  external  layer  of  tho  pericardium,  three  and  a 


half  iiie 

and  pun 

and   wa.' 

produce! 

fluid  e.Ki 

'lisea.sie  o, 

''•'eognize 

diverticui 

lii.s  ,'34  eas 

the  |)eric: 

glands  of 

in   tli(.   J,s 

•liioles  tlie 

acute  tul)( 

astinul  lyn 

i-<  in  a!]  (>,• 

astinal  and 

bronchial  ^ 

tissue,  and 

layers  of  tl 

faces  roughi 

ti"ii,  but  pr 

easeoiis  mas 

"II  botii  Jiiye 

tlie  peritonei 

probability  e 

tiisease. 

A  seeoinl, 

''■"III  the  lun 

ill   Case    XV 

ward  F  of  tj, 

'iii'iiia,  and  dj 

'I'ligs  and  boi 

was  stron^rly  .^ 

a  small  aniomi 

"as  smooth,  a 

reflection,  wjic 

ti'ated  pleura,  i 

And,  lastly, 

be  involved  wit 

tfie  serous  men 

■■*liowu  to  have  1 

peritoneuin,  wh 

'lie  peritoneum 


•'"-"'•^e  of  t,.,  .m..lia.tinal  ly„,p     1        '""""•      '^'"'^  "■"'--'•".ion  of 

'"«  J«  cases  in  whid,  (1,,.  ,»..;,.,,:  i  ■''' ^'''"''''^  were  oa^eous 

<!•"  .'s  tLcse  «,„,,,.  ,e,,,t.  a    i  "'  "r   T"^ '■"-'-'•     Ka«t.  wlo 

««"fe  .uheroulous  penlanli.i       ,  ^    r'''"'""  -''•'•^"'"-  ^^''-  -^''-•vi.)  of 

;-^-    an.,  ,„...,„,,;„  ,,an.,      '  :    •,  :";r'""'^  •!';  ""  ^^''^  ''•""'  '-"! 
:-''elMaI  .lan,l.  were  greativ      ,•  Z     ,      '  '•  ^•'"''    ""•-"'  '--e  vears,  the" 
'•-'^"-nn.l  presented  on  ...,,i,;    '' ,^  !' '''■''•'^^«'-'  ''eepl,  i.Uo  ,|,e  l„„g 
Z^-  '^^^  tlu3  periear,,;..,..  we  rj'  •;;:.;:-'-  ''I'l'-.-Kv.      .„ 


fac-e.s  r,nigl,o,u.,|  and  inr-i.lar'  „nf  ,.  '       7-7"--  '"^'ir  adjacent  siir- 

;;"  '^"'':  %-..     There  wer;  tat^'^Z^      '  ■'"'  ""'""^-  '"^"•""•^- 

Pfobabdity  entirely  .econ.hny  to        ,k''     '?"'■  '""'  '•'--  "^re  i    al, 
•''7--  "^      '""''^""■^■'""•""-i'-'an,iperieardial 

A  second,  lens  eonunon.  nuule  ..f  .....      •       • 
.''■"'"  f''e  lung.     A  verv  good  i    ,    1       '"f ',"   ''^  ^'■""'   "'^^  H^ura  or 

"•'''•''  ^  "^-tl-  John.  Hopkin    C    ;    ^:r"'   "•'"'   --  adndtted  to 

'•■".^•^  =^'"i  l..-h  aeu.e  and  ohroni;  i"..  V^'"^  T  "''^  •''■-^'-  ^'^'  the 
"■-  strongly  ...iherent  ,0  the  p  t.  :  'l  ""  ''''"''■  '^''^  '^^  '"'^ 
"  -"all  an.onnt  of  clear  flnM  ^n  '  ";  ^'"^^^^''^v  of  which  contained 
;•-  «->oth,  and  presented  a  nn  ^  ,"';"'"''^  ^'  "^  P-'-tal  lave 

;«oct.on,  where  it  was  adherent  "      J      ^  7'"""t-    "'^  '''^  -1-'- 

And  lastly,  there  are  instani.  i     w,.^       ,^™''  ':"''"^'  ^'"^-'^^e^- 
-"volved  with  thopleuruand  p     :         .t  ''"'™''f ""  ^^'''-^  ''> 
"e  serous  n,end)ranes.     I„  ,^J^  '.'"'"  '"  '^  S'^'-^nil  tuherculosi.  of 
shown  to  have  been  directlv    ran!    I    T  ""^  ^'"  "^"^^--"  -"     e 
f"<>"^'""- while  in  other:  it  won         '        '"  ""'  P^"^-«'-''i'Hn  into  the 


) 


I    S    ; 


f  .g* ;/ 


i,  '        1 

i 

t^^^H 

'!  1 

'!^^^^| 

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PhotDgmphic 

Sciences 
Corporation 


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•17 


^^"^^   <>.\  "^T^N 


23  WES1  MAIN  STREET 

WEBSTER,  N.Y   14580 

(716)  872-4503 


%-..*.    ^'^~ 


r/i 


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4  osi,Ki<:   rrHKKCL'i.ors   pkuicarditis. 

Moniiii)  Anatomy.- -Tlie  pietiiie  is  cNtrciucly  varied.  Pnu-tically 
there  are  two  groiijis  of  cases:  those  with  firm  adiiesioiis  between  the 
pericardial  layers,  usually  witii  ;,'reat  thickenin-j; ;  and  those  with  recent 
exudation,  lihrinous,  sero-fihrinous,  henio,  :-liaj^ic,  or  purulent.  Tlie 
cases  wilh  adliesious  are  tiie  most  numerous.  Of  the  17  cases  in  my 
series,'-'  cases,  Nos.  IX.  and  XVJI.,  nia\  he  excluded,  as  in  the  first 
there  was  nih  'uherculniis  infiltration  of  the  ])arietal  layer,  and  in  the 
other  an  eruption  of  tii<h  mill  u-y  tubercles  alone.  Of  the  remaining,'  1  o 
cases,  in  fi  onlv  was  there  tliiekenini:  of  the  layers  without  exudation. 
Thestatistics,  "however,  of  Itousseau  (Paris  Thesis,  i!S8l')  and  Lancereaux 
show  that  the  chronic  adhesive  firm  is  most  common.  Of  the  ;>5  observa- 
ations  analyzed  I)y  the  former,  in  21  there  was  adherent  pericardium 
while  in  12  (  f  Lancereanx's  14  cases  there  were  adhesions. 

IJotli  hivers  are,  as  a  ruh?,  uniformly  thickened,  and  in  the  extreme 
instances  it  is  im[iossil)!e  to  separate  them  at  any  point.  In  other  case,', 
the  ])rocess  is  more  local,  and  the  synechia  may  be  limited  to  the  front  of 
the  heart,  leaving  large  port  ions  of  the  base  and  of  the  left  auricle  free. 
The  reflection  of  the  pericardium  at  the  great  vessels  and  the  adjacent 
mediastinal  tissues  nuiy  be  uniliirmly  infiltrated  ami  the  vessels  sur- 
rounded by  a  solid  mass.  In  Case  X.  "  the  layers  of  the  pericardium 
were  adherent  and  measuiod  six  to  ten  mm.  in  thickness,  and  sh.owed 
<i-roui)s  of  tubercles,  nniny  of  which  had  fused  together  in  uniform  cheesy 
masses.  The  tubercles  and  caseous  masses  can  be  readily  distinguished 
in  each  laver,  since  between  them  there  is  an  intiltrated  connective 
tissue  which  is  free  from  tuiiercles.  At  the  base  of  tlu'  heart  the 
thickened  |)ericaidial  layers  formed  a  solid  cheesy  mass  surrounding 
the  aorta.' 

The  mendjranes  n.ay  reach  a  thickness  of  t'vi>m  three  t"  ten  milli- 
metres, the  increase  being  due  to  the  growth  in  the  leaves  of  tubercles, 
the  development  of  caseous  ma.sses,  and  to  the  new  growth  of  connect- 
ive tissue.  Fre(|uently  it  can  be  seen  that  the  two  enormously  thickened 
layers  are  united  by  a  clear,  infiltrated  tissue,  which  may  itself  not 
present  anv  tubercles.  In  the  earlier  stages  of  this  process  the  mem- 
branes are  little,  if  at  all,  thickened,  the  tubt'rcles  are  seen  just  beneath 
the  endothelial  layer,  and  there  may  or  may  not  be  a  fresh  exudate  of 
yeUowish  fibrin.  In  other  instances  the  contiguous  surfaces  of  the 
thickened  layers  are  covered  with  Hat,  yellowish  caseous  masses,  a> 
noted  in  Case  II.  Collections  of  thick  cheesy  ])us  are  occasionally 
found  between  the  layers. 

The  condition  of  the  heart  in  this  chronic  adhesive  form  is  most  inter- 
esting. As  is  usual  in  adherent  pericardium,  particularly  when  the 
layere  are  very  *hick,  there  is  enlargement  of  the  organ,  which  may 
each  an  extreme  »'rade.     In  (!ase  XI\^.  the  heart  with  the  thiekeiii'd 


rei 


)ierieardial  membranes  weighed  thirty-six  ounces.     At  the  tinieof  deati 


-"-  "'—.Of..   -...■.„.„,,,„ 


"   ■'  '^  J'i  lis  a; 

I'le  canliac  niu.sclc  ;- 

"•^i  'nay  Leseen  i„  th     .     ';  ""^'•^'  ''-i'lv  on^or..],  an    ]!. ,      1  "'.^' 

'"■'t  "e  had  both  DltMincv   .    .  "■^'"'■""•"i.  aii,I  if  ,,..,.  ff       ■ 

:^'-otu hordes  i„  both  la vuw"       "  "'""'^'^  "^'    '''-Iv  «en  n   '"' 

^'^-nchial  „an,,.  w   •         , '^ /'^'-'r"''"-".  also  ii.  ,.        ,         - 

'■  o.alrea.lyreforml  to  tho  i„H  '<''t-«i«le(l  e.npvorna.     fn   k'., 


'-r.MiAl,    HlSTOKV.— 


'irH 


W 


e  ii;ii 


care. 


^'-'V'.-  Latent  tnhorcloas 


y  recognize  f( 
J>ericar(li(is 


our 


groups  of  oases. 

A  considerable  number 


:"*,'11 


6 


OSI.EK:    TU  liKKCUI.OL'S     I' K  MI  C  A  R  DIT  I  S  , 


of  all  the  cases  ni  record  heloiiji  iiere.  Tiie  disease  is  discovered  acci- 
dentally in  individiiids  wlio  Imve  dieil  of  other  affections,  or  of  chronic 
]inlnionarv  tui)ereidosis.  An  interestiiijr  illustration  of  tliis  was  Case 
XI.,  a  well-nourished  old  man  of  seventy-two  years,  who  was  admitted 
to  mv  wards  in  the  riiiladelj)liia  Hospital  with  pneumonia,  of  wiiieh 
he  died.  There  was  no  suspicion  whatever  that  the  pericardium  wad 
involved.  As  already  mentioned  there  was  found  an  adherent,  greatly 
thickened,  tuberculous  pericardium  :  calcification  of  the  bronchial  glands, 
but  no  tubercles  in  other  parts  of  the  Ixidy. 

In  Cases  VI.,  XII.,  XIII.,  and  XIV.  the  disea.«e  was  also  latent,  and 
there  was  no  suspici(»n  of  pericarditis  during  life. 

Second  i/roiiji:  With  symptom:,  of  cardiac  ii. sufficiency  following  the 
dilatation  and  hypi  rtrophy  conseijuent  up(m  chronic  adhesive  pericar- 
ditis.    The  clinical  features  are  reai'y  those  of  cardiac  dropsy. 


1  tiftv-two  vears,  admitt<>d  to  ward   F 


Case   XIV.— W.  II.  T.,  age. 
of  the  ,)ohns  Hopkins  Hospital,  June  27th,  l.SS!),  complaining  of 
nes 


liort- 


if  breath,  swelling:  of  the  leirs.  and  incontinence  of  iirint 


Family  history  g I.     Fath 

age,  two  brotliers  died  when  youn 


(1  of 


acute 


pleurisy,  mother  of  old 


The  patient  has  had  scarlet  fever,  measles,  and  malaria;  denies  syph- 
ilis. Has  had  rheumatic  pains,  but  has  never  been  in  bed  with  acute 
rheumatism.     Has  used  tobacco  freely,  alcohol  in  moderation.      \Iv.  was 

11    an<l  stronu'   until   two  vears  ago,  when  he  had  a  "  bilious  attack," 

He  was  well   last  winter  until   Februaiv, 


ami  was  m 


bed  tl 


ree  weeK.* 


when  lie  began  to  be  short  of  breath  and  had  a  cough,  which  has  lasted 
until  the  present  time.     About   four  weeks  ugo  the  shortness  of  breath 


mcr 


eased,  and  hi>  feet  became  swollen 


vnf  rill 


(litifin  :  An  emaciated  man,  with  ilrv,  harsh  skin;  U'l's  and 


scrotum   a'dematons:   abdomen   not    sw 


illen.      Fulse,    104,  tens 


nsion   in- 


creased ;  temperature 


10-J 


Heart:   Apex   beat  faintly  visible  in  the  fourth   interspace;  palpal 


in  the  nipple  line;  fi^'cble.     Cai'diac  dulness  begins  as  high 

left  interspace,  near  sternum.     To  tlu'  right  it  extends  2..j  cm.  beyom 


)le 


as  .iccoml 


th- 


sternum 


th 


ere   IS 


no   thrill.     The  sounds  are  feeble;    the   se 


)nd 
u.-e  is 


louder,  more  marked  than  the  lirst.     At   the  apex  the  diastolic  j)a 
shortened — the  sounds  succeed  each  other  at  e.pial  intervals  of  time 


the  .second,  at  the  left  margin  of  .ste 


rnum,  is  re  luplic 


iited. 


Careful  exaniinatioiis  of  the  heart  on  the  1st  and  L'd  of  ,Iulv  sh 


owei 


as  a  special  fi'ature  the  llatiiess  extending  into  the  second  left  interspace 


th 


le   impulse  was  extreme 


Iv  iv 


II 


le  sounds  were  clear,  and  in  tlu 


thiril 


!llll 


the 


fourth 
rtil 


interspaces  (pii 


te  loud  ;  the  second  wi;s  accentuated.  A 


lortic  eartilaire  the  second  was 


feeble 


Lungs:  Clear  anteriorly  ;  resonance  defective  at  right  ba.se.     Thei'i 
were  numerous  rfiles  at  ba.'^e  and  cracking  rales  over  the  left  muini 


nar\ 


reirion. 


Abdomen:  Soft;  liver  and  spleen  normal. 

Urine  clear;  no  album. n,  no  casts;  sp.  gr.,  lOlO. 

The  case  was  regarded  as  one  of  cardiac  hypertrophy  nnd  dilatat 


ion 


osi.KH:    Ti; 


without  valve  d 


'^KncvLovfi 


''KHICAHDIT 


IS. 


h 


"iirs,  iiixl  sal 


i^ease.     ffo 


He  fiiilcl   rapi.ll 


"10  piiivos. 


waa 


I)roatl 


*:""!'<'y'''<'pe.i,;,„d| 


t'le   lieart. 


<^i"  ii'liiiission  tl 


ahovc  99 
.1  /'-/riiri 


C-^<-'ept  on  fl 


0  <(lC(i 


.'.''^•'•'i  ti.ifture  of  ,|i, 
j-;-ne  von-  (ivhlc 


ital 


'«  evorv  f;. 


CI) 


tl 


lorax  tlier 


i"ip<'i'atiiro  wafi  ]()■)'    | 


,'';.""\'->iin,Lr..friK. -„|' 


cyiie  Stokes 


"t  "'Kt  tl,i,<  Wi.l 


Hot 


risf 


;•'  wore  extc 


sac  was  oI,li,,.,,.„^,,, 


I'sivo  adiiesi 


).     I 


?iirfi 


ace  was 


COIlSIStill^r  of  fi 


i-vei 


■ywi 


The  1 


leart 


"lis  on  l)i)t| 


•"I'ltoiioiini   s 


ciall 


Tl 


y   oil    (he   surf 


I'm  connectiv 


lere  oovereil    I 


''W'lpied  an  ui 


1  f'i( 


'cse  exudat 


f"e  thiekc'st  h 


lon.-i 


i^'f,  iininoi 


0  timio  and 


a  veil 


averajrod  1 


t'liig  over  tl 


(MIS 

en 


o 
caseous 


iii.siiallv 
wish-wh'it, 


smooth 
Tl 


III  the 

It-   pericardial 


ai'^'o  area.     Tl 


f?i'ay  and  d 


matt 


'Pa.juc 


''I",  contai 


ii'iiir, 


'•  111  thickt  es: 


'«'sy  miliary    tuherel 


i;;::':::'-'^  ^'^  Hucken;:,  ;;•;::;!;;:,!'":'=-  v^' '' 


ess  over  tl 


10  wholt 


thirt 
witl 


y-six-  on 
mottled  (i 


'f'the  let't 


iices. 
ittv 


The 


l--a-diun,  a;,d  ti;:,  Z^Jlt^^'     ''■'^'  ' 


le 
ayer, 
OS  pe- 
es, 
ee, 


myocardium  w; 


10  l)ase  of  tl 


iirfa 


lioart, 


ventricle  the 


OKoneration.s  I 


tlHM.nlloftlH.jeft 


I'o  were  a  I 


'iioath  tl 


.'^  pale  yellowi.sii.l 


10;  aorta,  weighed 


10  end 


The  cavities 
potent.     Tl 


vontricle  was  LS 


''"■  parietal  tli 


'•ere  dilated ;  th 


mm.;  ofti 


"oardinni.    In  i] 
'•mnhi.    Th,.  ihi^,); 


•i'"wn,  sort. 


10  a 


"ere  a  little  thid, 


'<■  iiii^ral  orifice  ad 


10  wall  of  tl,, 


e  aortie  valves  sli.d.tlv.L 


I'lVht,  ( 


Koiieo. 


Tl 


mi  tied  three  fi 


""Ti;;:";,;;rj''-''«"«"H;i;:„t 


lore  were  small 


n.re,.. 


'I'l 


oiiod,  l)ut 


pex 

"ess  of 

'  mm. 


lings  wei 


'lit  tl 


many  gray,  til„.oi,i 


Tl 


li  d  rr"!:'^'-^  -•'  <i-Pi 


10  orifiee  of  tl 


niy  tiiherch 


10  valv 


com- 
0  segments 


on  tl 


contain 


;;^'-«;vei-eah,M.dantmil 


""^  ^'--  tXr:i;;"^'  ^"»"'^'""'"  ■•  t'l 


iperior  oavj 


10  endo- 


a  te 


opiupie  caseoi 


»•  miliary  tuherc] 


lary  tnhercle.- 


oy  contained 


OS  on  the 


i"*  masses 


tiihereles.     In  tl 
111  mucous  and  sul 


-  ^'.0, i™ ';;«;;:"■  Ti,o..,„ 


en 


many  in  streaks.     ThcOi!.';:'^"^-''  "  miinherOf 


cies  in  the  hr 


iiij. 


■«  iiitostines'there  were  ■.  i\        "'■^■'■•"'^'>  Pn 
t  u     e  I  lew  scattere.i  mil 


iihimic 


""«  'ayors,  l,i,t 


110   111 


cers. 


Tl 


■wonted  a  f 
mi"y  tiihen-les 


ew 


Jii  the 


lore  Were  no  tiil 


'iio  clinical  t;.at 
made  either  of 


chronic  adhesive  i[ 


)er- 


'ii-os  may  be  th 


I'm  "f'tiihereul 


SI 


as  in  the  c. 


mitral  insiifh 


i'SO  just 


mpio  hypcrtropl 


'•"(^  of  cardiac  d 


•'lis,  as  of  i 


impl 


J,'-' von,  there 


P'ly  and  dii 


atatii 


''"psy,  and  a  d 


pencnrditis, 


The  .1 


lagnosis  of  a 


'■'t'lioy  when  ther 


are  no  s 


0  IS  at  th 


Pocial  auscult; 


111  of  tho  I 


lagiiosis  is 


loart  whei 


"1  oases  adniittcl  with  d 
tation,  since  under  th 
•-""'•^''"■'ory  jdivsical 


"fiorent  jioricard 


.v-^piiioa,  dr 


mm,  alwavf 


pox  a  hnid   1,1 


Uory  sij,,) 


s,  or  of 
o"iii.ir  murmur. 


T/iir,/ 


'/roitji 


ese  circnmst; 
oxamination. 


opsy,  and  the 


"'"'^■'•fain,  is.hMihh 


moos  It  is  almost 


•>"is  of  cardiac  dih, 
possible  to  inak 


1111 


0  a 


mi  acute  liibercuh 


■iito  tiiberciil, 


lions. 


I. 


"is,  th( 


he  following 


'■•'IS,  either 


•sis.  TJie  clinical 


''^  "  .irood  ilhist 


^^oneral  or  with 


cerebr 


picture  may  be  tl 


lat  of 


glam 


Is  and 


pnmary  disease  bei 


Poricardiuni: 


iig  in  a 


'■""•»"  o<'  an  acute  i„i| 


osjiinal  manifest; 


prohabili 


h'  1"    the   me.l 


lary  tiibercii- 


•To£^'iS!;^]{''^';'!/^:-Urodtwe„tv-fi 

i  jviiis  nu.-itjif.'ii  .1.. ■-   . 

l"»S')f  strength.     () 
"  .i-'et  any  satisfact 


wing  to 


iiiuary  i'.",,  ]^qq 


mr  years,  admitted  to 


lastiiial 


ward  F  of 


men 


'"T  inlorniation  fn,,,,  (| 


t-.l  'i',-''^''  oonipiainin.r  of  coii,ri, 
lal  diilness  anrl  .,.,.,,1.  '"'■       'oiigh  and 


**«  'i'i<i_  apathv 


patient  as  to  I 


•'■was  ditiicijt 


lis  iiuiiil 


V  or 


1    ■i'C 


8 


OSLKR:    rrHKRCriiOrS    I'KRICAKDITIS. 


personal  history.  Ho  states  that  his  present  illness  began  only  three 
weeks  ago,  though  he  has  hait  a  slight  eoiigh  all  winter.  Sineo  the 
onset  of  the  illness  l.e  has  been  in  hetl  and  has  had  fever,  eoiigh,  and 
night-sweats.     There  has  heeii  loss  of  appetite  and  great  weakness. 

^J'r<:.'<nil  roiiiiaidii :  '{"einperatiue,  !(I().<S'\  Patient  looks  very  heavy 
and  dull  ;  there  are  sonles  on  the  lijis,  and  the  tongue  is  covered  with  a 
brownish  fur.  The  skin  shows  traces  of  a  .scpianious  syjjliilide  and  there 
are  well-marked  nodes  (ui  the  shins.  The  respirations  are  37.  The 
expectoration  is  niuco-purulent  and  is  at  limes  blood  tinged.  Tiic 
j)hysical  examination  of  the  lungs  gives  clear  percussion  resonance,  the 
note  perhaps  a  little  higher  in  pilch  at  both  bases  behind.  Anteriorly 
there  are  numerous  piping  and  moist  rales  on  the  left  side  below  the 
third  rib;  behind,  the  rales  are  universal. 

Heart:  Apex  beat  in  tifth  interspace  below  the  nipple.  Tlie  area  of 
dulness  does  not  ai)pear  to  be  increased.  The  first  sound  is  very  feeble 
and  niuHled  at  llie  ajiex.  and  possibly  accompanied  with  a  soft  murmur. 
The  seeonil  sound  is  well  heard  at  the  base,  and  both  sounds  are  uniisu- 
allv  loud  to  the  light  of  the  sternum  in  the  sixth  intercostal  sjjace.  The 
examination  of  the  alxiomen  is  negativi . 

During  the  three  days  the  patient  was  in  the  hospital  there  was 
irregular  fever  (from  10P  to  lO-'!''),  increasing  debility,  with  hurried 
respirations,  tremor  of  the  extremities,  and  gradual  failure  of  the  heart. 
The  bubbling  rales  were  so  numerous  with  inspiration  and  ex|)iration, 
that  it  was  impossible  to  hear  the  heart  s"  .mis.  The  examination  of 
the  sputum  was  negative.  The  urine  was  dark-yellow  in  color,  acid, 
trace  of  albunun,  and  there  were  several  casts  seen.  The  diagnosis  of 
acute  tubercuh'sis  was  made. 

Aniiijixil  I  by  Dr.  Welch).    Abstract:  Body  of  a  large,  strongly  built, 
well-nourished,  muscular  man;  macular  eruption  jiresent  on  the  skin; 
large  node  on  the  left  tibia. 
No  S])ecial  changes  in  the  brain. 

The  deej)  cervical  glands  slightly  enlarged,  containing  numerous  small 
tub(4'cles  and  caseous  areas.  Kxtensive  pleural  adhesions  on  both  sides. 
JJnth  layers  of  the  pericardium  were  adhei'ent  over  the  entire  heart, 
gi'catly  thickened,  and  contained  in  the  ineiiibranes  numerous  miliary 
tubercles.  The  anterior  mediastinal  lymph  glands  were  eidarged  and 
presented  numerous  miliary  tubercles  and  caseous  masses.  The  heart  was 
enlarged  and  dilated.  The  length  of  the  left  ventricle  from  a|)ex  to  edge 
of  aortic  valve,  I.'!  cm.;  thickness  of  wall  of  the  left  ventricle,  Ki  mm.; 
the  columiue  carnea'  in  the  left  ventricle  were  extremely  prominent. 

The  lungs  were  congested  throughout,  (edematous,  and  contained 
scattere<l  tubercles  surrounded  by  areas  of  pneumonia.  No  caseation 
except  in  the  tubercles  themselves.  The  mesenteric  glands  were  enlarged 
and  those  near  the  spleen  were  ca.seous.  The  kidneys  showed  much 
fatty  degeneration  in  the  convoluted  tubules. 

lu  the  following  case  the  tuberculosis  was  chiefly  manifested  in  the 
cerebro-spinal  meninges  and  the  clinical  picture  was  that  of  ordinary 
tuberculous  meningitis : 

Case  XIV. — John  T.,  aged  sixtc  .>  years,  admitted  to  ward  F  of 
Johns  Hopkins  H()s|)ital,  Js'ovember  "),  1S.S9,  con)j)laining  of  pain  in 
back  and  head.     Patient  is  well-nourished,  not  emaciated. 


^'••^!-KH;     'I'l^- 


II 

•••ll;  cl 


HKliCL'I.ors    I' 


'•■<  "'"tiior  is  dcn.l ;  fi,,),,.,.  (I 
tl  ree  week.  ui,|,    lu,„ia<i 


KHi'CA  HDri'ji 


vc 


l)n,tl 


lia 


^^('ekf 


bei 


'I'"  "i>.<(iiiiilelv 


.Sil 


coil; 


i«  iiiotlier  .li,.,l 
tired    /eeli 


"';r'  ;"'<l  «ix   sisters  J 


■''"ys  ii«  lias  I 


9 

'viii;,'  ami 
't'en  ill  t\ 


(empe 


.Vs'h-  luKfa  diii) 


":■-'■' ^■r;.;:trz"r"'!''-<^"'y/n 


'■iitiire,  '.)■') 


i">l  Imttles  t..  l,i,s  fev 
tL-mpcratiire  nwe  lo  im 
""  tlie  (!tli,  tl 


Aft 


ii  week  at 


iaviii.r   i„ 


;'"i|>cratiiren.se  t 


v«;  l.a.s  heen  in  l,e,I  I, 


'"  l)e(l  /or  two  I 


lor  two 
verv 


iit  «  I'.Af. 


'!'8^    If 


^'"'■I'l'd,  wliite, 
f:''»Mt  dislike  to  I 


'<■  I'xaiiiiiiatioii 


rev( 


'""■'It  i.s  rational 


pulse, 
iilcd  tlie  ti.ll 


'I'Hirs  with 
i^'P!<.^«i'<la(,Mietni.rhf 


OWillir;      'J 


>e  iiiov( 


'"'i^'iic  lieavih- 


;"!'^  dnuvn  haek,  and  wl 


'•T   'iu      nai     :inuii'<ii..  .      ^         •"••„tn;  n 


■^'>y"'J,'  tliat  it 


s'ze  and  act 
^f^ii't  sounds 
iic^'ative. 


'«  Jiaiiitnl,     'J"| 


'"'",""  "'>'"M't  is  n.ad 


".'  "'^'  '"ft  side  witi,  tl 


flows  a 


've.    Abil 


'>''c   clear  at 


'icre  IS  n 
"""■"  'lot  swollen 


paralv 


e  to  move  liim  | 


10  liead 


f';;  P'lpils  areofnie,| 


iKJt  tender.   .Si)le 


"'  resifits, 
iiini 


*'"  til"  7tli  and  ,S(1, 


■'Pt'x  and  at   base,     j 


^cii  not  enlai'ired^ 


tiie  teniperat 


he 


>"■<:  '-an-ed  from  It 
IP  'lote   read 


',"  "'"  'Vli,  and  ti 
clear." 

7"  tJie  9th  and  10th  tl 
'fiinie  iineonseioiis 


"iis  much  worse;  be. 


'Xaiiiinatioii  of  ] 


''     to  102^.     II 
'Sound.s  at 


'came  apathetit 


leart  was  examined 
"|iex  and  ba 


unn^s 


iml)!ed  ' 


'ase  are 


lie  be 


Att 


I"  uioningeal  svni 


aL'^ain 
Muite 


mies  the  an 


'IIS  and  l(Mrs 


and   the  disi.| 


larire 


ptoins  wei'e  n 


'.'."•''''•"tflv  dilated     ,., 
'i.t'y   distended  and 


'KS  .secme( 


SllL'' 


pliysiolou-icjij  ^,^ 

On  tl      ■  -  ■  " 
neck. 
12th, 


I"   11th   tl 


Abd 


convergent 
enirorgc-d 
'"'K  was  absent, 
ici'c  was 


a  littl 


>Uli 


'"•'■"  pi'onounced 
,  V--^  .Pa_ss,.d   involuntaril 


S'r:";i;."^::^!'-''"piis 


^'i'lint  in   left  eve;  tl 


-■  tlie    retinal    v 


"<'  swelling  of  'the   dii 


but  tl 


■eiiH 


tie 


omen  reti 


K-">d  deal  of  rigi.lit 


Tl 


Tl 


-'-'■  ^-tht;:ok\E!':!;:';;!:^''^ -•--■'' -'^ 


le  case  wa.s  i 


"■'•"  werenoii,uiM 


■"h'arded 


place  on  the  nior 


as  one  of  , 


ning  of  tlu 


'"''V'-zCbv  D     u^.;:'?'^^'r'''''"te„t 


neck  and' 


"1  inediast 


h:   AVelcl 


r:;:^'!h  ''r'''-''>'y  tuberci 


Abst 


10 


land   I. 


^'"••""t  to  the  pericard 


'ly  .just   beneath   il 


"''""  r"large<l  and 


'■act:  In   tl 


'"  to  the  hea'rt 


oils. 


tuberci 


witl 


snial 


Tl 


Him. 


ic  ensillirii 
nie  of  tl 


caseoii.* 


iiorax.  ir 


'""xtcnial.,„rfaeeoft| 


cartila 

!i(>se  (■• 


ge. 
and 


.■lands 
'^   verv  lai 


On 


at;  root    of 
'g"  caseous 


c  was  clo.selv  ad- 


^vere  full  of  „|j| 


"111  was  ji  , 


and  between  tl 

'"^  fi^'HMron,   two"t. 
'"It  ventriel 

weiir 


''''■^■'"--     The  two  lave     '^'^   ;'"""  ^^"^  ^''^^'klv  stud 


Jiass  of  partlv 


P"ricardiiini 


)  fourteen   mill 


caseous 


"ere    adi 


larv 
led 


partly  gelati 


icrent, 


Th 


>inineje  was   a    «n>nli  • "nuecre.- 

■l'"d.^42.n;;n,:.J"";.l',  ™^''^\'il'"d  wltl 
ie;'iiu.sclesul)stan 


Ventricle.  14 


■famines.     Tl 
'i"ii. ;  of  riirlit 


T'^^:  i'l   thiek,;ess.     O 


0  lungs  j)resented 


tl 


I'licath  the  pL, 
f  'lie  dia|)hrag 


'eiira. 


Tl 


niinierou 


mm.     V'al 


I   cheesv 
fc  was  fin 


'lous  look, 
'ver  the 


pus.     The  I 


lieart 


s  1 


''''"i?ulai 


""':"  were  no  tuberci 


\'cs  were  ik 
ii'eas  of  I 


iruial. 


Wall  of  left 


"'.  "xtending  from  tl 


es. 


On  tl 


'"iiiorrhage,  ehieH 


'"  pleural  siirfa 


».:iS;.ri,;:1-T  "''-l™'  •;:;:.  !;;*:;r';;™  ™  ii?  .^*'^;; 


'uhercul 


0  siiecial  cliam 


"lis  meningitis, 


'£" ■-'  'f' »ni  p;;:;,s 


:es  in  livi 


"iirth 


til 


he 


iij),  tl 


ff'-oi<J>:    C'ases  witl 


.     ,        spleen, 
"-  typical  jiicture  of 


lie  most  i 


'1    s 


"'P'"'tant   in   „,„„ 


ynptonis  of  acute 


tii»n  of 


pericarditis  is  acute  and 


sero-h'brinous,  h 


ace 


y  respects,  iiK-Iud 


pericardit 


IS. 


TI 


Ins 


>nij)anied  with 


les  eases  in  which 


'eiiiorrhagic,  or  purulent  cl 


more  or  less 


exuda- 


laracter.      Hen 


■M 


i 


!#' 


10 


O.SLEH:    Tl'BEIU'fLOUS    I' K  R  I  C  A  RDITIS. 


too,  tlio  procesH  may  l)c  latent,  as  in  Case  VII.,  a  young  man  ngetl 
twenty-eight  years,  wlio  died  under  my  care, of  litenioptysia.  There  was 
chronic  tiilicrculosis  of  hotli  lungs  with  extensive  pleural  adhesions. 
"Tin;  layers  of  tile  pericardium  were  united  by  soft  adhesions,  which 
could  be  readily  torn  through.  On  each  membrane  were  innumerable 
small  granulations,  and  here  and  there  a  nodular  tubercle  fnun  one  to 
two  millimetres  in  diameter."  This  case  is  of  special  interest,  as  it  shows 
the  first  stages  of  the  process  which  ultimately  causes  enormous  thick- 
ening of  the  pericardial  niend)ranes  with  universal  adhesions.  The 
tubercles,  when  small,  nuiy  be  readily  overlooked.  Acute  plastic  i)cri- 
carditis  in  chronic  tuberculosis  is  not,  however,  always  due  to  the  erup- 
tion of  miliary  tubercles.  In  two  recent  autopsies  on  patients  with 
ciironic  pulmonary  tuberculosis  dying  in  my  wards  there  was  siin|)le 
])ericarditis  witiiout  a  trace  of  tubercles,  and  with  little  or  no  exudation. 
The  following  case,  whicli  was  admitted  to  ward  E  under  the  care  of 
Dr.  Thayer  in  my  absence,  illustrates  the  mode  of  onset  and  the  clinical 
features  of  a  tuberculous  pericarditis  which  came  on  in  a  strong,  well- 
developed,  muscular  man,  and  proved  fatal  within  three  weeks: 

Case  XV. — John  P.,  aged  thirty-eight  years,  admitted  August  18th, 
with  swelling  of  the  legs  and  dys|)n(ea.  The  family  history  is  good.  He 
has  been,  as  a  rule,  healthy,  though  in  his  childhood  and  youth  he  had 
many  of  the  infectious  disea.ses.  He  has  been  a  moderate  drinker.  He 
denies  syphilis.  The  present  illness  began  about  two  weeks  ago  with 
pain  in  the  left  .shoulder  and  about  tlic  heart.  Feet  l)egan  to  swell  ten 
days  ago,  and  he  has  had  cough  and  shortness  of  breath  for  about  the 
same  length  of  time.  He  has  had  no  nausea;  his  appetite  has  been 
fairly  good.     Witliin  the  |)ast  'ew  days  he  has  become  much  worse. 

On  admission  the  patient  had  intense  orthopna-a ;  pulse  1,30,  but 
moderately  full.  He  had  a  distressing  cough,  with  clear  watery  expec- 
toration. There  was  great  (cdema  of  the  lower  extremities  and  of  the 
scrotum.  The  finger-ti[]s  and  mucous  mend)ranes  were  bluish  in  color. 
In  the  examination  of  the  heart  at  the  time  no  murmur  could  i)e 
detected,  i)ut  the  second  sound  was  accentuated  at  the  pulmonary 
cartilage. 

On  the  following  morning  the  patient  was  rpiiot;  respirations  28  to 
the  minute;  pulse  84,  the  beats  irregular  both  in  rhythm  and  force, 
the  Volume  fair,  and  tension  not  iliniinished. 

Thorax  apparently  .symmetrical,  but  the  manubrium  very  prominent, 
expansion  e(|ual.  In  front,  resonance  on  both  sides  good,  though  on  the 
left  side  flatness  begins  at  the  fifth  rib  midway  between  the  nipple  and 
axillary  line,  and  the  dulness  seems  here  to  be  somewhat  movable. 
There  are  numerous  sibilant  and  sonorous  rales  to  be  heard  in  fnmt. 
Passing  down  the  left  side  and  into  the  axilla,  the  breath-sounds  become 
more  feeble  and  fine  moist  rales  are  heard.  Pitch  of  res(mance  at  the 
extreme  left  base  is  higher  than  at  the  right,  and  the  vocal  resonance  is 
somewhat  diminished. 

On  auscultation  there  arc  numerous  coarse  and  medium  fine  rales  to 
be  heard  at  both  bases.  At  the  cxircme  left  base  the  respiratory  mur- 
mur is  almost  absent. 


Ffea 


It:   I 


OSI,Kt{:    TV 
oint  of  nmxi 


"ERCUI,()f.s    I'E 


HICA  H  DITIS. 


n 


T''  ''-vi-K  ..vj;  .rwi;;r '":'::""^;^  ''''««'"'^  ">  i.H.i 


111 

pi'oniinei 


"»ve  at  .socnd  ril,  „n,| 


'euli„|,.  praTonlial 


lizc 


s;=;l;  i;;rr'■;li^•r^"''• 


irr:::^r:''"^"'<'H.i.tor;i 


"•■™;    I'flativ..  ,i,ii„,i' 'i* 


point  (lu-ro  is  ,1 


't'  Jiinc'tK.ii  of  tl 


'I'  >t<'rniiiii.     'i'l 


"*'^s  extends  oiitwiir.l 


llllli-.«,s 


'*'  inaniihiii 


ic 


ni  iiiKJ 


to  11 


"vei;  a  very  ]i„,i„,| 


J'oint  nearly  .3  c 


"1.  outside 


Cm 


I  HI'  r. 


"•  "i.il  ,„■«;,.     F.  ,.-,,„„,., 


U'l. 


tlie  nipple.     (Chart  I )     Tl      i 


- ""  p-i^mion  in  uu. u^s.;;; -«,-•«  -1-1  in-;,:;;;;  :z 

lie  examination  „1'  tl  j  ■  1  w        '   '^'' =  *''"•'''«  no  traclie',] 
yei  nv-colored,  „eid.  ::^'     1  ""' ;;'f "«  ^^  "ej^ative.     K  '"^ 

''Valine  casts  were  found   ^ %,    -"^'/''^''''ct  trace  of  allnim  n 
remained  in  nn,.-j/,i       ;..     ^'"".'.'-:l'»"t  the  20f.h         """""" 


rise  in 
;'h 


m  nuieh  t! 


teniperatu 


le  isanie  condition.     On   tl 

t,>      1AA  rn  .  '-'"     tl 


■ind  I'lst  ti 


eliaracter;  at 


;•«  to   K)0.5°;  the  pul 


le  L'lM  th 


iii'ine  is 

several 

'e  patient 


noon  was  slow 


pu  se  varied  ^reatl 


ere  was  a  sliidit 


•-egular,  and  full,  from  70 


to  90 


.y  ni  rate  and 


I'er  minute, 


I 


12 


OSI.KH:    TC  liKIU'LLorrt    I' K  K  10  A  R  1)  1  T  I  S. 


iiiid  iiuaiii  was  as  lapiii  as  1  l<'.  The  patii'iil,  in  riiaiiv  ri's|)i'cts,  was  hi'ltcr. 
Till'  u'di'iiia  of  till'  li';:s  had  disa|i|ii'are(l.  Tlu'  iiriiii'  had  iiii'ri'ascd  in 
t|uuiili'y.  Mil  till'  lilih  only  \W  e.c.aud  on  the  'Jntli  ;}5(l  cc.  had  lii'uii 
|ia*»i'd.     On  tlir  '_'lst  and  li2d  the  amounts  wvxv  7iH)  und  1100  c.c^ 

2!{(/.  Till'  ti'iuj"  liitiin'  has  Ihtii  lu'twii'ii  07  '  and  iW^ ;  at  tlu'  nioriiiii;,' 
visit  llif  |iiilsi'  was  1  l.s,  ri':.ailar  in  fori't-  and  rliytlini  ;  llii'  rc'S|iirations 
.'>'2.  Tilt'  |iatiriit  was  lyiiii.'  ijiiii'lly  on  li't't  side.  Tlie  jiliysical  siiriis 
|iiai'li('aliy  those  iioleil  above  with  the  exeeptioii  that  there  is  an  exten- 
sion of  the  n'deiiiii  at  the  bases  of  tli'j  liiny.  The  patient  died  suddenly 
at  4.;)0  I'.M.  tii-day. 

Aittit/i.sinhy  Hr.  FlexiieiM.  Lar<re,  niuscular  man  :  moderate  (edema  of 
the  lej,'s  and  of  ihesiilieutaneous  tissue  of  trunk.  I''at  well  retained,  both 
lu'iieath  skin  and  in  omentum  and  mesentery. 

I'ericanliuni  is  adherent  to  the  left  pleura  ;  tlit'  sae  thickened  and  eon- 
tains  u  emisideralile  anioiiiit  of  clear  serum.  JJoth  layers  are  covered 
with  a  thick  lihrous  deposit,  looking  like  a  hairy  coat.  The  thickness 
of  the  peritardiiim  over  the  heart  iso  niiu.  When  incised  the  thickened 
layer  is  grayish  in  color,  with  many  opaipie  or  yellowish  points  scat- 
tered here  and  there,  often  continuous,  and  havin;^  the  well-recof,'ni/.e(l 
characteristics  ot  tubercles  of  this  iiiembraiie.  The  heart  was  j^reatly 
enlarired.  The  valves  were  normal.  Tiie  thickness  of  the  left  ventricle 
was  17  mm.;  leii^'th  of  ventricle,  sh  cm.;  mitral  orifice,  10'  cm.  in  eir- 
cu inference.  Thickness  of  rij^'ht  ventricle,  (I  mm. ;  tricuspid  orifice,  12 
cm.  in  circuiiiferciicc.  The  walls  of  the  auricular  appendix  are  almost 
coiiipleli'ly  converted  into  a  trrayish-wliite  material  with  only  a  thin 
internal  tilni  which  ajipears  like  muscle.  In  the  endocardium  of  the 
left  ventricle  are  numerous  eechymoses.  There  are  also  a  few  small 
ones  on  the  rii;ht  ventricle  and  in  the  auricles,  and  on  the  endocardium 
of  the  auricles  are  a  tew  small,  round,  whitish  miliary  tubercles. 

The  left  pleura  is  iimeli  thickened  ;  jiarietal  and  co.stal  lavers  adherent 
in  places,  but  wheie  not  in  actual  contact  there  is  clear  serum  between 
them.  The  costal  pleura  strips  up  with  dilliculty,  and  is  very  hard  and 
cuts  like  cartila;j;e.  Tlie  diaphragmatic  pleura  is  especially  thickened, 
and  on  section  it  is  seen  to  be  composed  of  a  dense,  almost  eartilaj,'inous, 
u'rayish  tissue,  containiiii,' yellow,  opaque,  ca.semis  masses.  The  apex  of 
the  left  liiiii;:  is  retracted,  hard  to  the  touch,  and  on  section  contains  a 
dense,  deeply  piLcmented  connective  tissue,  and  old  areas  of  caseation  ; 
no  I'alcilication.  There  are  a  few  small  foci  of  miliary  tubercles,  aiul 
scattered  libroiis  tubercles  elsewhere  in  the  lung. 

The  right  lung  is  voluminous,  and  in  the  greater  part  of  its  extent 
free  from  adhesions,  but  the  pleural  surfaces  present  numerous  grayish- 
white  elevated  ma.sses.  single  ami  conglomerate,  which  can  be  scraped 
oil' with  dilliculty.  The  costal  jileura  presents  similar  tubercles.  About 
the.se  there  are,  here  and  there,  fresh  iihrin.  In  the  apex  the  upper  lobe 
presents  a  few  foci  of  fibrous  miliary  tubercles. 

The  spleen  contains  a  few  scattered  tubercles.  Nothing  of  note  in  the 
abdominal  viscera  ;  the  intestines  did  not  present  tubercles. 

Here  there  wa.s  no  suspicion  before  death  that  the  process  was  tuber- 
culous, nor  in  reality  was  there  any  clew  to  indicate  that  this  was  the 
possible  nature  of  the  trouble. 

Tlie  followiuy  instance  is  the  only  one  which  has  come  under  my 


Ar; 


08LER:    TVnKlU'VUn-S    ,.K 


Motit-e,  ill  wliifi,  (j„,  ,|j 


iiiCA  i(  'iri'is. 


i;{ 


rensoiiablo 


<leyreo  of  j,r„|,„|,i|jt 


m^'llo.ilSofdilHMVIll 


"iitJHTiciiriliti^  w 


lis  made  with 


V\> 


iKin 


'■■  XVI.-K.  11 


'W'l  tl 


coniHamin.  of  pain  ami  mv.i'i 


iioi.j. 


WKinaii, 


Mini 

S, 

l)r(itl 

Tl 


.IIL'I 


"'A  "1  tlie  al)(| 


I'kins   H,.s,,i(al,  Julv'l 


la 


'■  iift   Cllllld  |„ 


KTs  and  four  Nisi ers  I 


'"'i'";''''  '!•<•  iiiniilv  I 


•iiiicn,  s\vidlin.r",,f  ,| 


•'olori'd  ; 
w  feet. 


't'  pill  It'll  t  i.s 
''"'gf-    Ha,sJiad 


1  Jiiarritd  w 


'\''"K  mid  w,.|r. 


iiMiorv  i.s 


d.     S|,(.  I 


Ills  tUu 


"  "1111111(1  Woman    \ui^  l>...i  . 


"!-  'his  liad  t„o  (,i,ii,| 


'■('11,  on 


Cm 


f  iiiiscar- 
)ofii,j„,loi(.ir„|ar  until 


I 


J*.    I'll  11  ,,,v:, 


'■'■   i'"Iat  illv;l. 


'WO  months  apo.     Since  el.il,?i,      i    i     ■ 

"       'i'«lit,  but  no  ex])ectorati()n.     Ou 


14 


t)Sl,Kl;:    TC  IIKIUT  l.ol'S    I'K  nil' A  It  KIT.'S. 


iulniisjtidii.tlu'  note  inadi'  liv  Or.  Tliiivt  r  wii.-i  as  follows:   liiill 


itT  fpart'ly 


iioiirisjifi!  Wdiiuiii :  ilorsai  ilt'ciiiiitii;*;  lips  and  niiicoiis  iiii'iiiltraiicH  sonu 
wiiat  jialf;  toiiiriic  sli;;litly  coated;  roipiralioiiH  ;;()  per  niiiiiilc;  nul.^ 
H(4,  rt'miiar  in  I'ircc  ami  rliylliin,  li'iision   not   incicasi  i|  ;  ti  itiiicratiir 


on  ailiiii.oio 


II  !tS 


iOxnansiori  ciiiimI  on  Imtli  .sides  ot'llic  ili 


ora\. 


I 


clear.     On  aiisculialinn  the  (tnly  almorinal  sij^ns  are  ti 
during'  ins|iiration  at  l>o||i  apices. 
Heart:  There  is sliidit  lieavin''  in  tlii 


eiciission  everywhere 
ni!   moist  rales 


le  eanliac  urea;  I  he  point  ol  luaxi- 


inutn  impulse  is  hard  to  ijitermine.    The  area  of  cardiac  diil 


iicss,  as 


indi- 


cated  on   <'li;irt    II.,    I)e;;ins  alxait    the  second   rih   and   extemls  far  t 


till'  ri^iit  of  the  sit'rnnni. 


I'lat 


ne; 


';,'ins  at  the  third.     TI 


outline  of  the  ana  as  iniiicated  is  triati;.qilar,  and  it  e.\tend.s  to  the  I..., 
far  down  into  the  seventh  interspace.     Thio  flatness  in  tlie  cardiac  re^jion 


ic  ;,'eneral 
■ft. 


is  di.-tinetly  inovai>lt 

On  aiiscniliition  the  sounds  are  tcehic  at  li 


le  apex,  liecome  louder  in 
the  fourth  and  liftii  interspaces,  and  are  still  more  distinct  ;it  tiie  hase, 
where  the  second  aortic  sound  is  accentmited. 

Aliiloniin:  The  aiidomen  is  full,  i.'eiierally  tympanitic,  and  the  walls 
are  a  little  tense.  Tiic  liver  tlatncvs  l.eirin's  at  the  seventli  rilt  in  the 
nipple  line,  and  extends  live  finjrers'  lireadth  helow  tiie  costal  mar-rin. 
The  I'd;.'!'  is  not  distinctly  pa!pai)le.  "^ 


The  spleen  is  not  paljialili 


T 


lere  IS  now  no  s 


well 


•wolleii  four  davf 


of  the  lej:s,  luit  slio  states  that   thev  were 


'J'l 


le  urine  was  cloudy,  acid,  sp.  ^'r.  I0I2;  sli-ht  trace  of  al 


suL'ar,  numerous 


leiik 


ICVtC! 


luiiiin,  no 


Diiriiijr  the  first  ten  days  in  hospii;il  the  patient  improved.     Tl 


peratiire  chart  shows  a  L'reat  incL'uhirilv.     Tl 
lis    or  its.,")  ,  .,11,1  ill  ilu.  afteri n.  hetueei 


le  teiii- 
le  luoriiini;  rciiister  was  at 


to  1(»1 


sometimes 


in; 


A I 


1  tour  ami  six   o  clocl 


risiiH 


I   ice-l)a;,'  was  placed  iiver  the  heart  and 


she  \va.s  <,'iven  stimulants.     For  the  second  ten  davs,  from  .Inly  'JDth  t,, 
Vugiist  f»th,  there  wa.s  distinct  improvement;  the  temperature  wa.s  lower 


and  only  once  reached  |I)2\     On  AiiLrusf  1st  it 


.f  dill 
mid  sternal  Hik 


was  iiuted  that  the  ai 


ness  was  diminished,  and   there  was  a   fricti ■iih  heard   in   tl 


eii 


tl 


svmT.roiioiis.  I 


lowever,  wi 


th   tl 


le  ciinliiic  movements.     Oii  the  .id  it  was  note.l  that  tliei 


cspiratory,  not  with 


marked  ruhliiivir  friction  jieard  in  the  second  and  third  left  iiit 
and  hoard  as  far  out  as  the  nipple  line  and  over  the  st 


V.  was  a  we  I 


ersnace,' 


eriiiim  adiacfiil  to 


these  spaces.     This  was  the  first  lime  since  her  admission  that  t'liei 


a  well-marked  frictioi 


1  soiimi 


1i 


pulse  lias  lieeii  very  variahle,  raniniit: 


Irom  US  to  1  !•_'.     The  patient  is  hri-hU'r  and  seems  to  lie  impr 
Between  .\u<ru>t  .Sih  and  •_'i)th  the  irre<Mil 


ovintr. 


several  iiccasions  rose  in  the  afternoon  to  li): 

of  pain  in  the  piueciu'ilial  re^'ion  and  of  iron,. ml  al),|oini' 


ir  fever  persisted,  and 

)1 


<m 


le  complained  at  timcf 


ilse  has  raiiLH-d  from  RIO  to  12.").    T 
■ate  1 


mil  pain. 


he  note  on  th,.  JTih  was  as  foil 


T 


le 


lere  is  mo,lerate  lieavinij;  over  the  lower  sternum  and  tl 


ow.- 


!(■  point  of  maximum  impu!.-e  is  rather  difficult  to  determine     Jielat 
•  lulno.ss   he^rin.^  at  the  .seeomi  rih  and  extends  well   to   the  rhdit  of 


tl 

d 

**.tt'rnuni.^    The  ah.solute  flatnc.-s,  however 

limit.    The  heart-sounds  heard  at  the  outer  limit  a{'  the  \\u\ 

feeble,  and  the  first  is  followed  1 


epi;,'ast  rill  111 ; 
ive 
the 


scarcelv  exceeds 


tl 


H'  norniii 


iiess  are  verv 


the  murmur  be^ 


t'ome.s  i(;U(lcr, 


wui 


.V  a  .short  .systolic  puff.     Pa.ssiiiK  inwaril 
'  it  <ii.sap|iear..,  above  the  fourth  rib.     It 


OSI.KIi;     11    UK 


"t'Lt.ofs     l-K 


th 


C  loWlTHlfllllllll    (I 


Kii'A  unn  IS. 


ITj 


••1  ff  til  rill 
"'  niiirtiii 


'11 


!• 


*'ar,  and   i 
iii^  lire  iiiiiri'  Jiit 


KTC  IS  (I  u,.|| 


■II 


''"t'liililiii-  j„  tl 


'">l«'<l  il.iiil)!,.  I 


ii.s  res 


"'■ii"ii  iiiiiiiiiiir,  N(,ff 


rofii  S.|,f,.„||„,,.  i^j  J 


"I"  f 


•'Vtr  liiis  |)(.r.Mi.m,.,|_  ( 


iiM'oii  <;.rci.,l  ii.snjrat 

ii>    »  1.. .    .   ..  t      •  ■         ' 


|H'<'t  tl  iMiicanliiil 


Hiivv  tilt'  ca.s..  ilail 


lull. 


iiiiiriiHir, 


"tti  todav 


"lis  as  ( 


*'iii|H'raMnv  in  t| 


"HOWS ; 


Tl 


"-•  inlfriiiittci 


It    I  VI 


;;;rr! ^v '^■■i-.*.,";;!:, ,; ,  :,™::;'s=  '■:■« .".o... ,■;:, 


"lore  nipid,  ( 


ahdvc  l();j., 


'';;:!:::;^'">:7'-:'-"-  ti......  i., ; 


"'7;^/;v,.r.lK.  t;.,u.,i,  andlifil 


Tl 


If  imlsc  has  1 


'Oi 


I    ('(IS 


l'''nissi,.n   til,.  (latMcssd 


tal 


ciirlil 


"•'•'"' ^"""l<lfal„Ct(.n,| 


•I 'I'll 


;'>:f';'"l.-  I.cy(in.|  til..  n>l,'t  | 


'•|'<'\   aiv   (;.,.| 
"iiiriiiiir  wliicl,   I 


l»''<  IKit    I 

t'r  iiC  the  st' 


'iJ,'<"^(iii  the  ri-lit  sid 


•Mind  tliciv  is  |„.ard   | 


"?^"'  "'"''  a!"'''"""'   nil.  i 
'•■  •><(iuiids  at'  til 


t'niiiiii. 


Tl 


lit 


patient 


I'liddcardia!   i 


"•••"IIK'W    llKilT    disti 


"■'•«  H  sliirlit  iKTicardial   ( 


niirniiir   is   | 


'"•'   toward   tl 


liiit  !l 


<'"iii|ilaiiicd  (Jii  ad 


V'lnl.      Of  lato   ,1, 


u'  fiisif: 


I'li'lKih 


I'lC     IS     I 


iiiiswidii    has  I 


('    Cd 


••^"iiiruliat   |,i;r|i(.r   || 


'"  •'>:|"ct(initi(iii.     Tl 


toward  tl 
r,W 


K'  iixilli 


an  at  the  ri,r|,( 


•('('(line   II 

'L'  |)('iciis>iiiii  I 


"1111   caiiilaT, 
".^'''   <•'■  wliicl,   il, 


•  sdiiicwliat  till 


and 


""■n  iimre  tnniM 
•'  at  the  left  I 


lul 


";;'tl.:|tli  liases.     Tlic  alid 


Hilar  M! 


Iireall 


I'aiii  III  it 
On  llie  l;;i| 


(•liiiraeter.     TIht 


"ny  H   /eelil 


eS(>|ii(. 
m^v  is 


"""■"  '^  "  I'ttio  till!  and  si 


er,  and 
e  arc  iiiiiiii.n,ii.s 


«lii('li  did 
tli(    I 


I  a  small 


ic    Cd 


iiiph 


Ills  d( 


iidi 


'|iiiiiililv  uf  111 


iicd  |iiini 


'•'''"!^'''':-■'■'<•^^eill^l^::!,n':;!;'''^"•''^ '''''-•'-! 


W( 


atiiiie 


•■ver^lias  persisted,  she  h, 
'  nis  (III   .Viiyiist  «|||  si 


'Vlit;   tl 


'■'""■•''"•"■•<  tinie.altl ^h 


'•nridllsly    CMdM.oh,  ,,,,,„, j, 


l-'!th,  114 
'^I'liltlnh 
natidii   the 
not  I 


"»  llio  2!)th,  10!) 


IKiiind 

ir 
•e  wa 


I'oiind 


'";  ".••'-''f<i  it'i  iidii.id 


■ptciiilicr  ,")i||,   IK, 


'<(•  TIk;  aliddiiu'ii  has  I 


.V  grained  in 
on  the  |(;,|,  ,1,^, 
and  Scpi,,|„|„,,. 


lint 


"•  '•'■ailil.Vdlitaincd.    '[ 


'."•■""letly  iiKivalile  dnl 


X'eoine  nidic  swollen.     () 


no  iiddiilar  m 


K'l'"  was  tender 


tlie  slerni 


a   ereakiiiL',  leal 


ini  was  iiKire  i 


xertediild  lielelt.     The  | 


lie., 
lie.. 


llidiif,di    tl 


in  tl 


II  e.vanii. 
neliialidii  c,„||,| 


iidw  iiicna- 


'"'ry,  Cricii,,! 


"iil<e(l,  and  tl 


iiaci 


live  at  1 1 
On  ih 


Tl 


'•  111  Ihe 


!*■   tactile   (i 


■ales  wlii(;|i 


.><dniid.     Tl 


iietidii  niiiniiiir 
'I'i'e  was  al.s,i  heanl 


i*i  i'e<ridii  (if  the  I 


iver, 

OVMI 


le  rii;ht  I 


)tl 


iiise. 


•■iniliis  IS  a  liti 


lire   heard 


physical 


Tl 


lero  IS  lid 


ard  1 1 


diit  aiiv  I 


I ilcrsid 


t(IW 

with 
loiid 


P''"n  in  the  epiVast 


'  "  ^vas  iKited  part 


<■  increa.sed,  and 
pleural  fiict 


"ver  Iheuhdlcdf  th. 


npaiMi  d 

"V  iiispiratidii 

iiiiir.s 

Hirlii 


-lunis  III   the  I 


C   llelw 


I) 


race  of  (VI 


ecu  (lie 


"•nlar.'vthat  tlr 
il 


ion. 


ivsiinaiiee  is  dete( 


'"•'n^'lhepa.si  week  tl 


"painticjiialiiv.     '| 


■■*'''|!"ila  and  the  a.vill 


pitch  of  the  I 


Iher 


At 


e  IS  incr( 


27tli 


"■'■  own  desire  tl 


''"'  I'e^'idii.  tl 
d 


;i'  patient  has  I 


lie  pern 


I  \vas  hii,riier,  | 


lial 


lerciissidii 


ml 


le  cdiicd 


'•aMii,- (edema  ahdiii  the  I 


I  IS  verv 


"■<-''!  Wdise.     Thei 


innrmiiis  ai 


patient   <v,'is  t; 


and  tl 


"'drrym^'  at   i 


•  lit 


Up  t(i  .Sopteiiilicr    I- 
rs;t  assistant,  I),..  'I'j 


ikeii  Id  ln.r 


ic  skill  ol  the  I 


e  Is  III' 11 
nVlu,  an 


>ac 


t    tl 


'loliie  on  .Sejil 


einlicr 


IS  with  cll 


iniprdviiin-.     I) 


^Idll, 


layer,  and  the  ea 


l:'''"'"f   '"xl   I'een    niidcr    tl 


sill'jcct    (if 


nriii:,r  (|n 


'"'  "'a'li   he  le/t  / 


so  was  reu-arded 


le  can 


or  mv 


time 


'"■  Ills  vacati, 


>s  one  i)f  pericar- 


St  rated  tl 
in 


several    vei-y  careful 


'^'  'ondiiidi,   td  Ih 


l"t'"'l.v  the  pidl,..,|,| 


'o  wiis  under 
t'xamiiiatidiii 
J^raduat 


in  sh 


*-'  seemed  to  !i, 


ela.ss   of 


'">■  «;"•*-•    i    made   her  tl 
-  "'Ill  rejH^ate.llv   d 


i^'ver  and  tl 


Ih^ 


po.«.«ihil 


1*'  marked  iiiv 


<:  '•'•''-e  of  fhe  tronlile.    '  Tl 


le 
enioii- 
eiis.sed 


">  dlth 


divement  of  the  | 


^  existence  of  tnl 


lerciil 


(ISIS. 


W 


,'.n<i''nts,  aiKl'dis, 

"'  persist t.iice  of  d, 

o  my  mind 

Hot,  however 


Mijrue 
0  CO 


<ted  t 


iild 


16 


OSLKR:    TUHKHCl'LOrs    1' K  HI  C  A  H  I)  IT  I S. 


lor  Slime  time  obtiiin  :uiy  s|)iitii  for  cxiimiuatioii,  hut  iifter  September 
1st,  oil  several  iceai^ioiis  she  hroii^xlit  up  a  imi('o-|Uirnleiit,  ami  onee  an 
almost  piiiuleiit  expeetoi-ation,  wliieli  was  very  tlior(iiiij;lily  examined 
with  Deifutive  results.  iS'olwithstamliiiL',  it  seemed  to  me  that  the  ease 
was  iiidike  any  ordinary  riieumatie  or  septic  periearditis,  and  J  felt 
justified  in  dictafinj,',  the  last  mornin;!;  I  saw  her,  "  that  the  protracted 
eourse  of  the  illness,  the  sii.'iis  of  pulmonary  trouble,  and  swellinii'  of 
the  abdomen,  makt'  it  proliai)le  that  the  patii'Ul  has  tuberculosis." 
'I'liree  ilays  after  her  return  liome  she  die(l,  and  we  were  liirtuuate 
enoni:h  to  secure  an  examination,  which  was  kindiv  made  bv  Dv.  J'le.x- 


uei'. 


'11 


lowmir  IS 


.1  /'/' 


an  abstract  of  Ids  re|)ort 
a  eonsidei'able  quantity  of  clei 


pentoncMi 


Tlu'i'e  1 

both    lavers    of    which     were    smooth. 


rum  in  the 


Tl 


eural  adhesions,  no  tubercles  on   either  layer.     The  jierieiirdial  sj 


lere    were    no 


)ace 


uncovered 


liv 


unjr  unusuallv   laru'e,    meas 


uriuij-   1")  li 


V   l!0 


larietal   pericanhum    is  evervwiiere 


ti 


ee. 


Ti 


cm. 
le    outer   surfaci; 


numerous  wli 


n) 


ite  elevations,  many  of   which  are  continent   and    i 


The 

lows 
IK  we 


[isscil  in  .some  places  than  in  otheivs.     On  incision  the  layer  is  greatly 


thickened,  in   placer 
d.      TIr 


:is    miicn  as 


()    mm.      About  .']()()  c.c.  of   turbid 

ith 


serum  escaped.  me  visceral  layer  was  every  where  covered  with 
ilaky,  yellowishwhitc  fibrin.  On  section  this  layer  is  "greatly  thick- 
ened and  contains  numerous  yellowish,  caseous  masses;  thus  the 
tliickiie>s  of  the  wall  of  the  left  ventricle  is  .'!  cm.,  nearly  one-half 
of  which  is  the  thickened  pericardium.  At  the  root  of  the  aorta  are 
masses  of  caseous  glands,  adheieiit  to  the  pericardium.  The  weight  of 
the  heart  with  the  thickened  sac  was  1 110  irrammes.  The  chambers 
wer<'  dilateil.     There  was  no  valvular  disease. 

The  lungs  were  voliimiiious,  contained  many  sciittered  and  conirlom- 
erate  tubercles,  many  of  which  were  just  beneath  the  pleura.  There 
was  diffuse  bronchitis,  but  there  were  no  cavities.  The  ijronchial  inlands 
were  caseous.  Li'-er,  spleen,  and  kidney  contained  tubercK.: ;  tliose  in 
the  spleen  were  large  and  caseous.  There  were  a  few  small  tiilierculous 
ulcers  in  the  small  iutivtines.  The  mesenteric  glands  and  the  glands 
about  the  pancreas  were  caseous 


Dr.\(;xos[s. — The  diagnosis  of  tuberculous  pericarditis  is  extremely 
uncertain.     In  the  large  group  of  cases  in  which  the  membranes  are 
thickened  and   united,  'the  dillicnlties  are  those  which  pertain  to  the 
recognition  of  adherent  pericardium,  dilliculties  which  are  enormouslv 
enhanced  by  tlie  state  of  cardiac  insufficiency  with  which  these  ca.-es 
usually  come  under  observation  fir  the  first  time.     In  children  with  a 
history  of  repeated  attacks  of  rheumatism,  the  bulging  pra'cordinni,  sys- 
tolic retraction   at   the  apex,  the  fixation  of  the  upper  liiuit  of  cardiac 
duiness,  and  the  diastolic  rebound,  speak  for  adherent  pericardiiiin  ;  and 
if  in  a  case  of  this  snri   there  has  been  no  history  of  rheuniatisin,  and 
if,  on  the  olln;r  hand,  there  are  indications  el.sewhere  of  tuberciilosi.^.  a 
probable  iliagiiosis  may  be  made,     in  the  ca.scs  which  set  in  as  acute 
pericarditis,  unless  there  are  evidences  of  tuberculosis  in  other  jiarts,  as, 
tor  instance,  in  the  left   pKiira  or  in  the  peritoneum,  or  there  iire  .'^i"■ns 


"f  'ocal  disease  in  ,|,,  |„„ 
"poctoration,  the  d 


.'UHi 


liilHTcle  hacilli   I, 


'■''"It  in  tiil.ercul 


cente8i8bepo,.f!,rMu,|"'i 
I'lvor  of  tnherciil, 


'»«"'>.si.s  ..an  nirelv  i 


lie 


ous  a.s  ill  i-j 


H!  iiiailc.     Tl; 


"'^■'-^  1)0011  foiiii.l 


ix'iiiiiiiti 


l"-^'-^^'"^'«"ral.l.„„lye.vu<l 


lie  eff 
"'  I'oricanli 


17 


ill  the 


"«i"i)  may  he 


ti.s 


ir 


J)ai'a- 


<'^-)  T': :":/■:-»''«. .:iw:.^::rI;:;!«*"-' 


"   """'<!  seem   „r„| 
-xiidatioii  (I 


^  f  "j-l    fbatui-e.    the;..: 
"'     >r()hahe    tl,.,.    ;..    ,, 


'   '"'vo   hu'ii  /;n,i)d 


11 


XVI 


'I'  OI.|Jr.s>  is  ;,| 


.'■';'.  '■"   the  onlinary  f 
'"  '"y  «'i-ie.s,  the  d 


ore 


'"t   '"   Hie   acute 


^^'«    "«;■•■  ....    eriteria.  th 


cases  with 


>u<rh 


'".■""•"^'ft''J  and  the  fe 
^';'''-,  "'  Poneanlitis;  and 


foro-fihriiio 


vor  more  irreir,,!. 


load  to  a  St 

'I 
card 


n.iii,'-  siis 


ovolo|)iii,,„f  „f  (lifji 


111  such 


li  a  ca: 


'^'••ArMi;\T.~It 


'I'lciiin  (hat  ti 


"■■'0    S|>r„,s    i„     tJ,^>    J 


lUS 

111- 


•0,  as  in 


"">'   niav,  as 


'■■'  not    iM.|,n,|,al,|e  ,| 


''t'l"'oce8sis(„|„,,,,„, 


oils. 


ini<rs  nii 


f>'etely.     I 


ossi 


ihly 


'I  >^iiiiihir  })i 


■()('('; 


some  (,f   tl 


«''^' instances  oHieale.!  tul: 


'c  oases  of 


111    tile   |),.,. 


••"    luliercnh 


^is  of 


'"  -'I'l   iil<olihood   f 


l>eroulosis.    The  el 


'i"i|>le  adi 


'toneiim,    ret 


Jtori- 


•over 


'ii'onie  adI 


'"■'■''lit   pericardi 


com- 


iim 


-S-:;r:;:;r";i-5'S:::7:;;;:-:~:;;; 

'  :"'"""^''^'"-  '■"  "I'i.'li   he  dete,.,e  '  '""'  "  '"•"^•"■"•'"lor  o.i  a  c  ■ 

"'  ''"-^"'lliointicnt'    t--      ,      '"'"I'oncanlial  ruh      FT.      .'*     ^      ^'^ 
'''""'"'  '^  'iionds.  hut  aimrove,)  M  "''"'  ""thin- 

"'    ;""oauayto.e,h..r.     '  ( )h    1,,',     '''"■-""*''•''  "vatment   ...id 

-".5;';:;^;:;;;:;;r'r-!-';:n: 


""«'"fl'"l.i.l.it.inPhiladel 


"•^".vofthecohlof  (I 


I'liiii,  of  iisin.r  J 


10  ice  hat 


oiler" 


oil.lh 


■"liiiiis  eom- 

aiid  in  sueh 

'■"IimIi  which 


!  i 


n'l 


18 


OS 


sLEH:  rrHKHcrLors  i- kiuoa  u  ditis. 


tlic  wairr  tlnwi'il  .■niitiiiMoiiMy,  am!  il  ('"iild  l)c  arraiiLTfil  t"  liavc  any 
tciii|K'nitiirr  lliiiiiiilit  tii'cossary. 

Asccniiil   iii(liralii>n   lu«Ms  jntn]   in   tulinviildiis  as  in  otluT  lornis  of 

pcricardilis  -wli-n  llic  dl'iisi varlu's  a  ivrtain  irradc  and  the  pnlse  is 

in'i'i;-iilai' and  t\'r\>\r.  tlic  ri.l.n'  licc(iniin,L'  I'Uil,  tlic  rospiralions  luirricd, 
|iara(rntc.-is  slmnld  lu'  pt'i'loriuvd.  or,  if  necfssiiry,  tin.'  sac  fivuly  inci.si'd 
anil  drained. 


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ilsc  is 
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icifsc'il 


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:s.   - 


<LXX 


ONDILATATIUNOFTHECorOM 
^N  VOUNG  CHILDREN  ^'''''''' 


I  upon  its  seven  t  . 
long  career  it ).  , 
of  literature,  a  t 
le  leading  mii'  .> 
Original  ArticK  ; 
ed  Summaries  jf 
specialists  in  tiie 
ny  original  papt'is 
OBsess,  and  such 
foreigi\  works  that 
'ears  destroyed,  it 
!  world  to  medical 


liV    W.M. 


USLKR,    M.IJ., 


U"'v.,.s,t3,  and   •■hy.e,a„-i„.Chii;  "" 
J<'1"'«    Hopl<i„s    Hospital, 
l^altiiiiore,    Md. 


Kt^piiiited  from 

i">lK    AkCHlVES   OF   PlC.IATKICS, 
I'V-bruary,  1893. 


•s. 


Nkw  Vcikk: 

M.J.   ROONRY,   I'KINTKH  AM,  Vuu 

114-120  \V,  30th  St. 


;  subscription  list, 
J  writers,  teachers, 
f  practical  notes; 
sped  under  their 
vilized  nations;  a 
idequate  presoata- 
dicnl  literature  is 
correspor,  deuce  is 
mportance  in  the 
lUped  under  news 
tvery  practitioner. 
1  magazine,  The 
!  value  of  the  two 


92 

luring  tSi;!,  inali 
either  or  Imih  the 


392 

r  lao  patients  perl 
o  patient  ivcekifl 
pages  of  t'ssortedj 

m,  VisniN'i  LisiJ 


9Jf  STRfST. 


Pr( 


of 

pal 

uni 

or 

the 

hyi 

stai 

the 

or  t: 

deat 

habi 

earh' 

obsti 

circu 

with 

an  o]: 

short 

a  gut 

vvitJiii 

A    : 

I'hilac 

Hug-hi 

early  i 

more  i 

ally  er 

after  t 

rectal i 

In  his 

t-'onstip 

went  ni 

lie  was 

or  vomi 


ON   DILATATION   OF  rur. 

iUN   OF  THE    COLON  IN    YOPvr 
CHlLDRExV*  ^OL.\G 

-  -I'lpKins  University,   ni„|    i>i,     • 

H"Pl<.n.  Hosp„..,l,  ,ia|,i,n„,e,  Md.      ''>^"^'»"-"-L-hief.  Johns 

s^£ii"^'^-"^itli!^;^i:^:;,:^j'-  cco,,  by  no 

pat  o,;   T,f  '^°'^"ionIy  associated  wftlf  i'"'""-'  P^^'^^'s 

or  of  tl,e  s^-.'^o     'f  ^^'«".  either  ofth    e'S,,?  h  f.'*!''^    °f 
there   are     welvc  .w''"''^'    ^''"'^  '"  the     u  e   '"  ?^'^'' 

earliest  takty.  "1,"  t"";'""', " ^  "hk     ev""?„'r  if'" 

^'t.'n-s.+      liie  patient-   nk  "^^  jh    r660   by  Dr   W   ir 

early  infancy  with  Z  'i.nt  ^' '^^''^''''^^'  ^vas\ro ubkd    n 

eUal  injections  seemed  ra  h  ,r?.  "°'^"^''i^-  "ot  hard.     The 

or  vomiti^'^^lCe'r:"''^'  '^'^  ^^'^'-^  ^va.s  "  eJe  'arfr'"'' 
-rrr-^ ^ ililf^^^seemed  to  do  but  in  ^  P^'" 


-<>,-.'ca!  Society,  vol.  xiii. 


if 


Osi.KR:  Dilatation  of  the  Colon  in  Yoniig  Children. 


stroiiy   purj^ativci   alone  sc 
first   seen 


cinctl   to  be  clTectual.     W'lien 


enlarLTcd,    cvct-\ 


b>-   Dr.    Hu^^hcs,    tlie    belly   was  enormously 
wliere  txmpanitic,  and  showed    tlirough 


the  thin  walls'  -reatly"  distemled  coils  with  waves  pf 
peristalsis..  The'  chiUl  died  in  an  attack  of  acute  colitis. 
The  autopsy  showed  nothin^^  remarkable  except  the 
colon,  which 

pints  of  water 


h  was  enormously  dilated  and  held  fourteen 
atest  dilatation  was  in  the  neigh- 


Tl 


le  trre 


ur  inches 


borhood  of  the  sigmoid  flexure,   where  it  was  fo 

in     diameter.       The    muscular  walls    were     enormously 

h\i)ertrophied    and  increased    in   thickness  towards   the 


anus. 


T 


lere  we 


re    a  few  shallow,   rounded    ulcers,   and 


about  the  middle  of  the  transverse  colon  a  large  area  of 
recent  inflammation.  In  this  case  the  excessive  dilatation 
was  definitely  associated  with  constipation,  and  Dr. 
Hughes  was  of  the  opinion  that  ine  continued  use  of  large 
enemata  had  aggravated  the  tendency  to  distention  of  tlie 
intestine. 

One  can  rcadil\-  understand  dilatation  and  hypertrophy 
of  the  colon  being  graduall\-  induced  in  consequence  of 
protracted  constipation,  but  there  are  instances  in  which 
apparently  from  the  earliest  period  of  life  the  large  bowel 
is  inert  and  in  which  there  would  appear  to  be  a  tendency 
to  dilatation  without  any  protracted  impaction  of  i.xicc^,. 
The  following  cases  are  of  interest  in  this  connection  : 

Case  I. — John  T.  W.,  colored,  aged  ten.  was  ad- 
mitted to  Ward  F  of  the  Johns  Hopkins  Hospital 
Feb.  17,  1892,  complaining  of  a  swollen  and  painful 
abdomen.  The  boy  was  brought  to  the  hospital  by 
his  relatives,  who  live  outside  the  city,  and  as  they 
were  not  seen  b\-  the  attending  ph\'sician.  no  his- 
tory could  be  obtained.  It  is  stated,  however,  that  he 
had,  for  many  \'ears,  trouble  with  his  bowels,  and  had 
al'vays  had  a  large,  prominent  abdomen. 

Present  condition:  Sparel\-  built,  somewhat  emaciated 
lad,  weighing  only  fort}--seven-and-a-half  pounds  ;  lips 
and  mucous  membranes  of  good  color.  The  ends  of  the 
bones  are  not  enlarged,  and  he  is  not  bow-legged.  He 
is  able  to  walk  about,  but  the  abdomen  looks  distended 
and  large.  There  is  no  fever  ;  the  pulse  is  quiet.  When 
stripped  the  contrast  between  the  distended  paunch  and 
the  emaciated  thin  .'imbs  is  very  striking.  (See  Fig. 
from  photograph.) 

The  thorax  is  symmetrical. and  the  lower  zone  is  much 
distended  by  the  enlarged  abdomen.  The  ribs  are  a  little 
beaded.      The    back   shows   several    reddish,   superficial 


,4 


Osi.KR: 


^'I'^f'^tionoft/u'Colonin  Y, 


'"'"IX  C/iildn 


scars,  wlicrc  the  cJiiu 
pulse  cannot    be    Jis- 

tinctly  localized,  but  is 
apparently,    under    the 
f'j  li  nbanda  little  in- 
£l;'^'   the    nipple     line. 
j'lo  sounds  are  clear' 
the  secoiul  a  little  ac- 
centuated.    'J- he   ex- 
amination of  the  kuH^s 
's  negative.  "" 

The  abdomen  is 
greatly  distended 
measuring  sixty-tliree 
cm-  just  above  the 
"aval  It  is  uniform- 
on  palpation  ten.se,' 
painless,  and  no  tumo.' 
masses  can    be  felt. 

i'ercussion  gives  every- 
where a  tympanitic 
"oe.      The   spleen    is 
no    palpable,  and  the 
splenic    dulness    is 
masked    by   the    t^-m- 
Pany.    The  edge  of  the 
''^j''   cannot  be  felt 
and  dulness  is  obliter- 
ated    m    the     middle 
Parasternnl  and  nipple 

Tlie  urine  was  nor- 
mal. 

Nothing  very  de- 

^f  Tu     determined 

^f^^'t^boutthe  nature 

°\  the  lad's   illness. 

jJiere    was     certainly 

"^■'ther    ascites    nor 

tiimor.   and    the    sucr. 

gestion  that   it  might 

be    tabes  mesenterica 

was    negatived.      The 

ch.ld  was  kept  in  bed 

and  given  a  good    diet      Ti.      a 

J'^^-^P-tal  he  had  an  ordTnarv    mn    ■■''  ''^"^'   ^^cond    day  in 

""t  specially  constipated    '    "'^^^'^^nt  from  the  howds" 


4     Osi.l'.K:   Pilatatio)!  of  the  Colon  in  Yoiiti}:^  Childrin 

( 'n  tlic  J2il,  lie  had  iliarrlui-a,  six  lar^e  liquid  niovc- 
mciits.  Oil  tlic  23d  and  24tli  tlieic  was  only  one  niovc- 
mentoncacli  day,  and  then  for  three  daj's  he  was  consti- 
pate'l.  Repeated  examinations  showed  practically  tiie 
same  coiulitinn;  enormous  abdominal  distension  without 
any  obvious  cause.  Me  complained  of"  no  pain,  and  we 
very  soon  let  him  yo  about  the  ward.  At  intervals  he 
would  be  constipateil,  but  this  was  readily  relieved  b>-  a 
dose  of  castor  oil,  and  never  durin^^  the  months  of  h'ebru- 
ar)'  antl  March  ilid  he  go  for  more  than  two  ila\s  without 
a  movement.  On  several  occasions  he  had,  even  with- 
out Ciistor  oil,  loose  fluid  motions.  All  this  time  he  had 
no  fever,  and  was  up  andabout  the  ward,  and  gained  four 
|)ouiids  in  weiglit. 

On    tile    night  of  the  23d,  the  patietit   had    four  loose 
lluiil  movements,  and  complained  of  abdominal  pain.  On 
the   morning  of  the  24th,  lie  vomited  several  times,  and 
the   abdomen  seemed  more  distended,  and   the  contrac- 
tions of  the  intestinal  coils  were  verj'  plainh-  to  be  seen. 
On   the  night  of  the  24th,   he  was  given    several    large 
injections  which  brought  away  formed   masses  of  f;eces. 
The  abdomen  measured  in  its  largest  area,  seventy-four 
cm.;    was   t\'mpanitic   throughout;    not   verj'    tender    on 
pressure.  The  individual  coils  during  peristalsis  standout 
very  plainly.     The  outline  of  the  colorfcoultlbe  distinctly 
seen,  extending  obliquely  from  the  left  lumbar  region  to 
the  tip  of  the  xiphoid  cartilage.     The  examination  exter- 
nally and  per   rectum    could  determine  no    tumor.     No 
flatus  cou'id  be  obtained  with  the  rectal  tube  passed  high 
up,  but  relief  was  obtained  by  introducing  the  tabe  far  up 
ami  irrigating  the  bowel  thoroughly,  and  with   thisa  large 
t|uantit\-  of  fluid   came  away.     The  distention    persisted 
throughout  the   25th  and   26th  and   27th  ;  the  vomiting, 
however,  was    less,  and    the  injections  gave  relief.     The 
tenderness  was  less,  and  the  (iistention  of  the  abdomen 
was   not  so  marked,  being   only  sixty-nine-and-one-half 
cm.    on    the  morning  of  the  27tli.     He  was  very  much 
better  the  next  day,  but  on   the  29th  he  developed  facial 
erysipelas,  and   was  transferred  to   tlie  infectious   ward. 
Here    the    erysipelas     ran  a    regular    course,    with    very 
moderate  and  irregular  fever,  which  persisted  with  inter- 
missions until  the  lOth.     When  in  the  isolating  ward  the 
abdomen  w.is   not  so  distended;  he  had  several    attacks 
of  constipation,   but  the  bowels  were  readily  moved  by 
laxatives.     During  this  time  he  had  also  several  attacks 
in  which  there  was  great  pain  in  the  abdomen  with   in- 


5 


'''J^lome.i  was  very  lart .    m  '"'"'"•"  ''-■t^rn  to  Ward  F  the 

°[  pan,  and  vomiting,  'u  no  t  ,  ''^' l"^^''*'' ''"''^'^•^ 
!^ttacl<.s  was  the  material  1  ron  h  V"  '"^'^'-^  vomiting 
^'•^Tuu-e  ahvay.s  reiiev J      .^^^^^  '"   character 

were  given  uitl/  tl  e  hh^' j -'Z^'   '"^^''  -'"cmata.  uhich 
'"-,-'  '"  as  possible  £,;^',^-'';-'..a"cl   l<^tting  a^ 

i"i-   increased  freciuenrv     f  m     ^         ^  ""^^  '^'<^t- 
vomiting  made  me  fee    tint      u     T?  u'''''^^-'^'"  °f  Pain  and 
an  c.vploratory  operu  on    ,  '"''  ^^  ''^'v'sable  to  have 

-''^■tl.er  therc^vL        "'       ;f 't^  '"  cietern^ine  definitd; 
dul  not  seem  possible  tntlH.-         ^ '^^ /••"^''^'-■.  though   it 
a/   the    fluids'passe  I     o  fr  ;rr'°''^''^'^'''>' ''bstruclio, 
Accordingly   he  wnl   ,     '"^ely  from   the  siphon   svrin.r, 

-nt  on  If^Hl'^l^ra    rU  "'rir ,''"  f '^■-'  'CS: 
nal  section.     The  follouJn^'  •    '''■'^'^^'  Performed  abdomi- 

f-mthesurgicar/r^S^:^  "   '''"  '''''^'''  "^  the  not  s 
Lender  ether  a   Ion     •     •'• 

line  extending Vrom  a  Hulebelor.r'^'"  I"  '^'^  "^'-^^•'■''^n 
to  a  little  above  the  pnbe  VVh  n  J'  '^"^°'™  ^'-""tilage 
P  etedan  enormouslv  e„?i,.,,H'^"  '^'^^  'ncisionvvas  coni- 
abdominal  walls.  The  S,  "  ^  ''  '''  °"^  ^'P""  the 
tJie  greatest  at  the  sW;  n  ^"^  ^^■•■'^  enlarged.  ^It  was 
mentwas  c.xactly  fo/tVfiTe  ?f,f  "'-^V^ ''^re  the  measure- 
C;x-cum  was  abont  ha  f\his  si         '",'-'';:^"niference.     The 

^'vely  increased  in  c^-L'eer  in  ;'n'        '^''  l""'"'^  P'^^^^ 
and    descending   port  "is       T         '1'^^^^nding,  transverse 

-..sted  on  itself.  Ct  Z\o  alto  ."^'"°''^     '^^■^'^"■^    ^V'  ' 
puruig   the  operation  the  re?,,  °  '''"'^  ^">'  obstruction, 
necl   by  Dr.  Osier,  whose  fin   eTl^onl  I  '^'■^"gl^'y  -^am- 
tho  hand    of  the  operator    ami  n.^"'^''^''''>' '"'-''t  by 
determmed   anj'where      A   mod       .  '^^'•."'^ture   could    be 
existed  in  the  rectum    nof-  '"^^'^''-ite   sized    f;ecal    mass 
tl>'-^  the  tube  was  pa?sei  Vut  Se'?'-;''"^;  ''''^  ---"-v^^o 
emno-   itself  through     his      fe^''^^^"^^'  ^olon  did  not 
normal   in  size  and  appea^^^nJ        T*""    'ntestines  were 
■ntest.nes  were  wrapped  in  "'-,'  '""''  "'^'■'>'  ^'"Pty-     The 
Padced  around  the  i^S.'on        ™  ^'"'^-  ^^^^'^''  ^''-^^  also 

opening  uri;'oweTarth:^;;tft  '°  "'''•'^''^"  -^'fi--'^'  anus 
moid  flexure.     A  very  hrT     '""°"""^"t  Pa-^t  of  the  sie-' 

^-cal  matter  esfap^ed^J^f  ^„,f -^;;y  -'  yellowish  fli^l 

^as.     The  muscular  coats  of 


fr 


0    ObLift  :   riirnfatioit  of  the  Colon  in  Young  Children. 

the  bouol  were  \ci     iiuicli  thickened  ;  the  mucous  mem- 
brane seem».Hl  normal. 

Tlie  hoy  diil  remarkably  well  ami  was  sitting  up  in  a 
chair  on  April  J9th.  His  a|)petitc  anil  general  condition 
improved  ;  he  f,Mined  in  weiglit,  and  he  had  no  further 
abdominal  sj-mptoins  whatever.  There  was  no  tympa- 
nites, and  he  passed  the  fiuces  throuj^h  the  artificial  anus. 

Unfortunatel}-,  we  have  not  been  able  to  obtain  any 
account  of  the  first  years  of  this  child's  life,  further  than 
that  he  had  always  had  a  prominent  abdomen,  ami  had 
trouble  with  the  bowels.  It  may  be,  of  course,  that  the 
enormous  distention  present  when  he  came  under  our 
observation  was  only  the  sequence  of  protracted  consti- 
pation, but  as  mentioned  in  the  history,  there  was  not  at 
•ly  time  during  his  stay  in  the  hospital  impaction  of 
fiicces,  and  the  attacks  of  distention,  colic  and  vomiting 
were,  as  a  rule,  readily  relieved  by  simple  injections,  and 
at  no  time  were  hard,  scybalous  masses  seen.  The  grade 
of  dilatation  in  this  case  was  extreme,  a  circumference  of 
forty-five  cm.  (about  eighteen  inches),  which  equalled  the 
circumference  of  the  ascending  colon  in  Dr.  Formad's 
case.  I  must  say  that  the  attacks  of  vomiting,  with  in- 
crease in  the  distention,  great  tension  of  ihe  abdominal 
walls,  and  visible  coils  in  active  peristalsis,  excited  the 
suspicion  that  possibly  there  was  a  stricture  of  some  sort 
in  the  sigmoid  flexure.  It  was  for  the  purpose  of  explor- 
ing the  large  Mtestine  that  the  laparotomy  was  performed. 
To  have  made  an  artificial  anus  in  the  case  seems  a  seri- 
ous measure,  but  the  child's  condition  had  become  very 
distressing,  and  the  rapid  improvement  which  loUowed 
the  operation  is  itself  the  best  justification.  Dr.  Piatt, 
under  whose  care  the  boy  is  at  present,  informs  me  that 
the  boy's  general  condition  is  good,  and  that  it  is  his 
intention  to  try  •;'.■  'eestablish  the  continuity  of  the  bowel. 


by 


Case  II. — R.  A.,  i^  L-.  ver  n.onths,  admitted  June  12, 
l89i,withconstipi"i  n  '"a-V.-;  and  motherare healthy  and 
well.  The  first  1 'fti  -i.  v>r;i  Novemh.'.  ?o,  1889,  natural 
labor.  At  about  the  i,ev.  i.^ih  month  uie  child  had  stom- 
ach   trouble,    continued   diarrhoea,    and    died   suddenly. 


m^ 


^>.slkk:  W,u,Uu.,.  oft,.  Colon  in  Youn,  CluUnn.    7 

'^^rSi.  ''S:'\^:^i,   When  born  was  a  heaithy. 

chilcls  napkins  were  no      ,l.^''^n^;h7'""'    '."'■'^  ^''^ 
swollen  and  very  tens.,    i,,.  fiV     i  '  '^ '''^''""len   became 

nation,  passed   a     ,      e't.  'l  t"' 'n    T'^""  ''"  '-■•^■^"^i- 

were  bru'u^lu  away  Fro^  I  '.'  ^  '';'>1<.  tar-like  faces 
has  had  only  five  o,  s' Tu  I  "V  '!'  '"'•'''  ^''^^  '^''''J 
examination  .,f  tl,,.  rectu  u  ,  •  "'•'V""P"'-  ^  '-'•^'•eful 
child's   birti-    '..,(,,,...•  '■'   "'''•'^'   •'Shortly  after  the 

was  hard  an<l  u.  ^v  tl  ifHaZ^ -'"'^'^  "\^-  ^^-'^'l  "latter 
this  the  chihl  throve  ml  s  .mi  '"''""^^■'''  J"  spite  of 
"""rished  and  ch\l  not  •  or  u'!  ''^T'^'^''^'-^^^'"'  ''^'  ^vell 
so  Ions,,  as  the  bowe  wJrV  horn  "l"  ''''■^''■'^">'  '"'^tressed 
by  the  injection/  irnr^r-''''f'''7^"''  everyday 
would  swell  and  the  cil.l  won!  I  '"■'•'  ^''"  ■'bdomen 
t'.mcs  large  cjnantities  ^f  rate  'u7,m''  ''''^'  '""^■''-  ^' 
bile-stained.      Until    two  w  .'l  1  '  '''''''  «<""etimes 

healthy  and  looked  naturnl      A    .^^''  "'"  .^^'"''''    •'^^''-^■""l 
reverisl,   the  ,mu,,,     erst^  h^'  began  t„  be 

and  had  much   vomitinVul  en     i  '  k  ''■^''' ''  ^-^'''-'''t  ^''-^ 
hcved,  and   the   mothe    is  s   ,-..      "  ^°''''-' "■^'''•-^   ""t  re- 
Pain  when  the  abcio    en  was  Sis    "'' I  T  "^r^'^'  •'^■^''  "<" 
weight  and  has  not  nursed 'o  t^'''^'^'^'     ^^'  ''^^   '"^t  in 

wi;'nS;:^s;;:('i;;th- .!;;:5i^l:;f'"^  ^"""-  ----tcy 

no  teeth  as  yet  cut  T  o  .hT'''  '"'^'r  '  ^'">«^^"-^  ''^  clean  ; 
and  very  teJrse.  lM,e  c  fst-U  .r'"  ''^  ^^'•?">- distended 
cartilage  are  strongly  ev^rteclrf'"'  'r''  ^''^  ^"'^'''■"■-"i 
of  the  intestines  are  d.stinci  n-„  ■  ^"",'''""'  "'^  ^'^^  ^o-'J^ 
coil  passing  transverse  tt^i  en  the''  "''T''  '''^' 
ensiform  cartilage.     There -m  no  ',''"''^'    ''^"''    the 

-sible,  but  the'motherst'ues  ImTv"'"'  T''""''''' 
^^^en  verv  plainer      ()„  rvunnf       ?i        -'  '""^  "f^ten   to   be 

•va.scs;  no  tumorTbe  fc/  b  /  f"'^  pressure;  no  faxal 
of  flatus.     The   liver    Inl!;  ^^^'"''^  '■'  "^"^h   gurgling 

spleen  is  not  palpal  le'Th^  "  '''"^'"^  obliterated  f  thf 
by  the  finger  is  nej  ive  iuHd'l,  1"'^'°"  "*"  '^'^  '"'^^tum 
sphincter  was  cspc^i  N^-t;  J,  A^'  "°^  ''^"'^  to  me  that  the 
sequently  examined  tl  c  c h d  1  M  I"'  ^•'^'^^'^-  ^ho  sub- 
more  resistant  and  tighter  th'mn'^^'''  ''"'{'  ''^'  ^  ''ttle 
passed  withot,t  any  ciifficultv  and  7"'-  ^  '''^^'''''^'  '^ 
tance  of  eight  inches  ,r;,,^i  ^'    ^  ^^'^^"  '^  reaches  a  dis- 

been  a  prevVoLi  i,  ectirof\f;Yerfl'^- 'ir'  "'^'  '^  ^'^^^  ^a^ 
routine   the  mothir  roU:::;^^^^^^,^^^^^^ 


8     Osler:  Dilatation  of  the  Colon  in  Young  Children. 

inject  a  few  ounces  of  water  an  hour  or  two  before  she 
passes  the  catheter,  which  she  then  inserts  to  a  distance  of 
about  six  or  seven  inches,  and  gas  and  faices  come  away. 
The  abdomen  becomes  flat  and  soft  at  once  after  the 
escape  of  the  flatus  anti  fuces.  The  contrast  between  the 
tense,  enormously  distended  abdomen  in  the  morning 
after  having  been  for  twenty-four  hours  without  an  evacu- 
ation, and  immediately  after  the  use  of  the  catheter  is  very 
remarkable. 

The  j)atient  was  only  under  observation  for  about  two 
weeks,  and  presented  no  change  during  this  time.  The 
distention  ditl  not  seem  to  be  due  to  obstruction,  nor  did 
it  appear  to  be  influenced  at  all  by  the  use  of  free  injec- 
tions. The  mother  was  advised  to  relieve  the  child's 
bowels  with  the  catheter  several  times  in  the  day,  so  as 
not  to  allow  the  flatus  and  f;vces  to  distend  the  colon. 

The  mother  wrote  seven  or  eight  months  after  she  left 
the  hospital  saying  that  the  child's  condition  remained 
practically  the  same. 

Here  we  may  possibly  have  an  illustration  of  the  early 
condition  which  leads  ultimately  to  the  enormous  dila- 
tation and  hypertrophy  met  with  in  the  last  case  and  in 
the  one  reported  by  Formad.  From  birth  there  seems  to 
have  been  an  inability  in  the  large  bowel  to  empty  itself, 
and  this  certainly  was  not,  I  think,  associated  with  any 
degree  of  tightness  of  the  sphincter,  through  which  the 
index  finger  passed  v/ithout  any  difficulty. 

The  important  matter  in  the  treatment  of  these  cases 
would  be  the  careful  regulation  of  the  diet,  and  in  very 
young  children  relieving  the  distention  by  irrigation 
several  times  in  the  day  so  as  to  prevent  the  accumulation 
of  liquids. 


'dren. 

fore  she 
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(Rki'r 


Physic  and   Physicia„; 


AS  DEPICTED  ,N  PLATO. 


^""^  ''^'"''  ''->^'-  //"//v>„   /,,,.,,„,    .,.  ,      . 


BV 


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'X   PJ.ATO. 


'n;iMCTKI) 


ductory  remarks  -i,,  1  .,   i        •  ^f"'''ci"e.     After  i„tro- 
systematic  .stiidv  of  tli.."  Hi,  ,"  •  '     ?  l""oceede.|  to  a 

'" ;""'--  -  f--H.';i-  r;;-  ;:;x    '^'''^ "" 

and  j,'yiia;colo.rv.     Am,..,,,  ,  •  '  ''>«'«"e,  sur;;ery, 

If'euned.  not  tL  let     i  ?,     '"  \"^  "''«r«^  ^vhicli  ^e 

-■'Lout  a  I-'i.  iu  t  ;/  ei     ee    o/'a.? /"  "'^^  T^'^''''^ 
"l"!,'.V.     Min.ls  in„„isitiv7  r!       **'  ""'"y  »"<l  pliysi- 

several  amon^  the'  .  e'CJ  i "    r?' ""!  "*'  '"'"'  '  »"'! 

o<=lt'.s,  and  Democritns  IT.  ,  -^ ''"'^'"'''is,  Emped- 
little  of  their  view  ^  .ve^/t^;?"?-'''^-  .^''  "^""^^  but 
wl.ich  thev  wrote.  ,k1'  '«  *'"'>J«;''""  me.lieine  on 
ever.    Diogenes   La^r  i  ,s    L  ,  "         '^'"""critus,  how- 

'"fiicai  w7iti,H.s  V h     : '  '';';;'*^''T'  '* '!«'  of  his 

)oB.sof  the  worLs,.  i  '  rr  ■'  '"  '■*^"'"'^^  '"  "'« 
whose  essays.  ••  O  .  Tho  e  """'  "'"  "^'^'  "*'  °"«  of 
Cou.d.  after  , line's '^-itter  "•''  .^"'""^^"^  ^i^'' 
'ii.sease,  which  Dare.nE,  t  !  ,'     ''?^'''^'^  «f 

'^r;:;:Ed^;:i^'t^^f^'i:"2;r-'''°-° 

-■'iiei.:;:l;X';'r;;  'VhT'^'^v^^ 

science,  with  ..vmnastics^'.u',!  ■  ."  .'"'''"'"•"■'^I'ip.  with 
i'"H,ine  an  AUien  u  ^  h^.:'  fTl  '  '"'H  "^>:-  ^^"^^-^ 
century  worrie.l  alu.ut  t  e  en  e  M  ?  "1 "'"  ^""'"''^ 
growing  la,is,  askin.  t  m  ad vj  t    f      '"    '''  "^  "'"^  "^ '''« 

-Bpiciou.  cough,  c^s'.dlll^'^'r"'?'^^ 
laureas  for  a  systematic  co,rrs  P^Ia^stra  of 

Socrates  a.Ivised,  "  when  In,  n  n  .f/*""=*^^"=^ '  «>•,  as 
-king  the  assistance  o  1  H  J  '  !^'  T  ^''^'^'^'^'^  " 
son,  the  "hero.,,hvsici.  n"    1  ^  ^^'""°'  """"fe'''  ''*« 

J!'  IW.i.laurus  o/ at  AllsiSf  T' ;Vr  '^^^^^^^ 
''- over  his  parental  trouble^attho^rmrofte^S 


teeiitJi  coutury  lie  would  j,'nt  u  iiiort;  exact  tlinjjiiosis 
ikiid  ii  more  luiiiiiial  trciitiiiciit  ;  In;  iiiij^lit  travi'l  fur  to 
liiid  Ko  ftiiiiifiit  ti  '*  )ii'(il't't<»ui'  "  of  ^yniiiaxtics  as  Miccus 
for  Ills  l)o_v,aiid  in  C'liristiaii  seiciu'e  or  failli-lii'aliiif{  he 
would  liiid  our  liasturd  subtititiite  for  tlii>  stuttdy  and 
gracious  \vorslii|i  of  the  4l'lsciila|iiaii  Ii'm|de.' 

From  tile  llipixieratic  vvritiiij^H  alone  we  have  a  very 
impertVct  knowledge  of  the  state  of  niedieine  in  the 
most  brilliant  |ierio<l  uf  (Jreuian  lii8tory;  and  many 
details  relating;  to  the  character  and  to  the  life  of  phy- 
HJeiaiis  are  "gleaned  only  from  se(!ular  authors.  So 
much  (tf  the  daily  life  of  a  civilized  community  relatt's 
to    problems    of     health    and   disease    that    the    ^reat 


writers  of  every  aj^e  of  necessity  throw  an   important 


-   _-_,  ..„_   _-   --_ , „ 

Hidelii^ht,  not  only  on  the  opinions  of  the  peojile  on 
these  tpie.stions,  but  often  on  tiie  condition  of  Kjteuial 
knowledi;e  in  various  branches.  Thus,  as  Dr.  IMlinj^s 
has  just  told  us,  a  considerable  literature!  alreaily  illus- 
trates t\n'.  medical  knowledge  of  Shakespeare,  from 
whose  doctors,  apothecaries,  and  mad-folk  much  may 
be  leathered  as  to  the  state  of  the  profession  in  the  lat- 
ter part  of  the  sixteenth  ceiiniry.  So  also  the  satire  of 
Moliire,  malicious  though  it  be,  has  i)reserved  for  us 
phases  of  medical  life  in  the  Keventeenih  century,  for 
which  we  scan  in  vain  the  strictly  medical  wriiini,'s  ■>( 
thai  period;  and  writers  of  our  own  times,  like  (jrtiorj^e 
Kliot,  hav(!  told  for  future  generations  in  a  character 
such  as  Lyiigate,  the  little  every-day  details  of  the 
strnjigles  and  aspirations  of  the  profession  of  this  cen- 
tury, of  which  we  (ind  no  account  whatever  in  the  liles 
of  the  l.ancet. 

We  are  fortunate  in  having  had  preserved  the  writ- 
ings of  the  two  most  famous  of  the  Greek  philosophers. 
The  great  idealist,  Plato,  whose  "contemplation  of  all 
time  and  all  existence "  was  more  searching  than  his 
prt^decessors,  fuller  than  any  of  his  di.sciplt^s;  and  the 
great  I'calist,  Aiistolle.  to  whose  inemoiy  every  depart- 
ment of  knowledge  still  pays  liomage,  and  who  has 
swayed  the  master-minds  of  twenty-two  centuries. 
From  the  writings  of  both  much  may  be  gathered  about 
(ireek  physic  and  physicians  ;  and  1  propose  this  even- 
ing to  give  you  what  I  iiave  culled  from  the  "  l)iak)i:ufs 
of  I'lato."  I  shall  lirsi  speak  of  his  jdiysiologioal  and 
pathological  sfieculations ;  then  1  shall  refer  to  the 
many    interesting   allusions  to,    and  analogies  drawn 

'  For  ail  account  of  "  .Kscul.ipliis  at  Kpidaunis  mid  Atliciis"  soo 
DyiT's  "(Iciils  iif  dri-cce"  ^Mn(!.Mj|laIl,  ISiH),  a  I'liaptiM-  which  oi>ri- 
taiiiK  alMi  arii'xeidlentilliiciission  nii  tln'  r«iiilii)n  of  Hcc'iilar  to  (iriotly 
liimliciiic.  Ill  CliaptiM- III  of  I'atcr's  ili'li;;!!!!!!!  sloiy, '■  MMriiis  i  hi- 
Kpicuii-iii,"  is  a  ilcscripliiiii  ol  .me  ol  tlic  Uoiiinii  ,Ksciilii|ji:i,  auil  an 
Rccoiiiil  ol  Uic  inclliiiil  of  proci'ilurc  in  tlie  "  cure,"  tlic  riiliculous  as- 
poctH  of  which  are  so  graphically  di'seriheil  in  the  "  I'lulus  "  of  .Vriii- 
lupliaiies. 


«.J:r';^St!:'e::;i;:''''-''-''-o."y  an.,  ,,,,„, 


*''''""^."''«rv  l.o,i,V.s  of       ',,'*'  •'"^'^'"""^  "f  the  four 

«'0""«t,uretoo,s,;a|,' Jr''-.  ',''^"    ""'  «^<'m.  of       « 

'"•";"  "^'•^''-  -'<i  the  0  1.?;;:^  ^'■'"'"'"•^'  «'"'  ^Vo  .     t 
""*''«•     "God  took  mo.  o  '''*■'' "'  "'«  ''"''y  *vere 

«;''ole  race  of   aiuuC         '"' ;V'"Mv,.r.sal  Hce.l  of  U ' 

"n..sa«  tluMl,irer..ut  kin   s   .7  '^ '"''''>'  =*'"'    various 

<''^".'«  .see.!.  In,  „,,,ie  ,'0  'fl  ,'  '  '  '  ''"*'  '"  '■**'=^'iv«  the 
''";^"'"  "»•  M'e  marrow  '1:7  T^'  >*"-'  c-H.'-l  tint 
«"'<«Hl  wa,s  perfected,  le'  ?'"'"'"  "'^''  ^''-'  aa 
■^•'•"^•e    .shonlfl    1,,  „,       ''',  ^'''''^  containinic  this  S 

'^''V?'  ^" -''tain  tie  ri:;;''"^   ^t  whid.   was      : 

2";'.  -Hi  |.e  ealle.1  .he,a"    |     ,;';  '"■"  '■""■"' -"i  elon- 
""'  '"  tl'e.se,  as  to  anchors      .r  """"  '"'arrow'- 

-'"•...  frannnvoJk    o,    >^^ho  h  """  ""'""'   ''"'•" 

' ''."  account  of  the  s,ru '  mwV       '"'"  '"  ''""«•"  ' 

^"-'--  of  -pirutioirs^  ,""rr"'""^''-^""'»f 

„■.'•"« <'-io«„o, Of  i,,,n,    ,,„     "       ""•  '*'"'  '^"•^■"lation  is 


miiiil<'Ilij;il)'t'  to  oiirnioilcrii  iiotioiiH.      I'liito  km-w  lliat 
tlio  hloiiil  \v;iN  ill   coiiMtiint   iiiolioii  ;   in   H|ifakiii^'  of  in- 
h|iir:iti()ii  iiik)  ('\|iiniii(iii,  iiiiiI  iIk-  network  of  lii'«  vvliicli 
int('i|iciii'ti!iii'H  ilic   IkxIv.    lit'   hitvH :    '•  i''or  wlicn   tlio 
rt.'s)iiriition  \h  mnufi  in  iiiiil  out,  iitiil  llie  tirtt,  wliicli  it 
fiiMt  liouiiil  witliiri,  f(illo»8  it,  tiiiil  ever  iiiiil  anon  mov- 
ing to  mill  fro  ciiterH  tlic    liclly  ami    ri'iitiicH  tliti    iiiciit 
mill  ilriiik,  it  lii^^oi^('H   ilit'in.  ami  iliviiiiii;;  tht'iii   into 
Biiiitll  iiiii'lioiiH,  mill  ;;iiiilin<;  tlicin  tliriiu<:li  iliu  passii^cH 
vvlii're  it  j,'ot'H.  |)Uin|i.H  them  iim  from  li  foiintiiin  into  tlio 
cliiiiiiu'N  oi  tilt!  Vfiiis,  tiii<l  nudes  llti'  ili  earn  of  the  veins 
Jluw  tliruugli  llie  body  as  lliiough  <i  conduit."     A  ctiin- 
|ilfte  circulation  was  iiiiknovvn  ;  liut    Plato  ii  iticrittootl 
fully  that  tlif  lilooil  was  tlio  Hoiirct-  of  noiirisliiiiunt, — 
"the  litjiiiil  it.-t^lf  \\v  call   hlooil,  which   nourinhus  tlio 
(U'hIi  ami  tilt)  whole  lioily,  vvlientusall  parts  are  watereil 
unci  empty  spaces  tilleil."      In  the  youn^,  tlio  triaiii,'le8, 
or  ill  inoilerii   parlance  we  woultl  tiay  tint  utoniH,  aro 
ne-.v,  anil  are  compared  to  the  kt^el  of  it  vessel  just  oil' 
the  stocks.     'I'liey  are  locketl  liiinly  tont^tlier,  but  form 
a  soft  ami  tlelic'att;  mass  fre.ihly  iiia^le  of  marrow  ami 
nourislietl  on  milk.     'I'lii!  prottess  of  ilij^eKtion  is  tlt;- 
scribeti  us  a  strujij^le  between  the  triangles  out  of  wliitili 
tiie  meats  and  ilrinks  are  cumposeti,  ami  those  of  tbu 
botlily  frame;  anil  as  the  former  are  oliler  and  weaker 
the  iiewtT  triani,'les  of  tht!  body  cut  them  up,  and  in 
this  way  the  animal  j,N'ow,s  f;reat,  lieincr   nouriglied  by 
a  multituile  of  similar  particles.      'I'lie  triani^les  art;  in 
coiisiunt  fluctuation  anti  cliani;e,  anti  in   the  **  Sympo- 
tiuin  "  Socratt!s  makes  Diuiima  say,  "A  man  is  calletl 
the  same,  ami  yet  in  the  short  interval  which  elapses 
between  youth  and  aj^e,  and   in  which  ttvery  animal  is 
said  to  have  life  and  iili;ntiiy.  he  is   ui;derj;oiii{^  a  per- 
petual  (irocess  of    loss    and   reparation  —  hair,    llesli, 
bones,  ami  the  whole  body  are  always  chanyiiii;." 

The  tlescnjition  of  senility,  euthanasia,  anti  death  is 
worth  tpiotinj;  :  '•  lint  w  lu^i  the  roots  of  the  truinj;li's 
are  loosened  by  liaviiitj  umleii,'oiu!  many  eontlicts  with 
nii.ny  things  in  the  conrst)  of  lime,  they  are  no  loiijjer 
able  to  cut  or  assimilate  the  food  whiili  tMiters,  liulaib 
themselves  easily  tlivideil  by  the  botiies  which  come  in 
from  without.  In  this  way  every  animal  is  oveicome 
and  tiecays.  and  this  all'eetion  is  calletl  old  a<;e.  And 
at  last,  when  the  bunds  by  which  the  triangles  of  the 
marrow  art;  united  no  longer  htiltl,  ami  art;  parted  by 
tlie  strain  of  existence,  lliey  in  turn  loosen  the  bonils 
of  the  soul,  and  she,  obiaining  a  natural  ndease,  (lies 
away  with  joy.  For  that  which  takes  place  accortliii:;; 
to  nature  is  pleasant,  but  that  which  is  contrary  to  na- 
ture is  painful.     Ami  thus  tieatli,  if  caused  by  tiiteaso 


•!-''-r""l,':;,;x^±'''''''^':''- 


''"'  'i.'iit  ,,t 


iiiitiir.'  JH  il 


_'  '•'Mllfs   witli  „|,| 


lint 


*'<'|n|Miii,M|  Willi  ,,| 


If 


""    'Msi.'st  l.f  ,|,.,,| 


■■';,'<■  .111.1  (iiliii, 


IllOlIf     „f 


H'lixiiPf  nitli.T  II, 


<l<'H<Til.,.,|     i„    tl 


"•■lUi'i  and    th 


''■»"  «ifli  pitiii 


!'■*.  mill  in  no. 


I'llll'IIH."   I,,., 


«  ."'ifun,  ..f  ,|is«,4se, 


in   k 


118 


IiimI 


V  (irisi 


Hll 


r''*'""-"' tl...  r.i..,,,, 

'"  'I  w'lMi;;  .,n|,.,..      w     ; 
7.''""H  kin.ls  „f  I 


'•'•t  Hci.'hw.      I'l,,.  ,1 

"        ■'"IV""""'  "'"   »'<M.,'  ,.| 


^""•Ws,iii,|  f|,,,)| 


'■''I'l'i;,'  >vitli   tl.i, 

llM'itSCS    of    tllH 
It'll. ...Its 


tllil.k» 


s.  an.  (|,„s,.  „c  ,1 
vvlioJe  c-,.„r.s„  „f  ,|,„  |„„| 

;y«'    ITIMlllCMi   |,v  ,|is,.,,| 


Tl 


llllllll'IIC 

11'  Worst    of 


Hit  of 

'in:  |iroilu(.,.|j 


■"  '■*.  '•U.ilM,,,.,!  to  til 


IH 


spinal   marrow. 


V  M  r 


'tH'er 


'/•I 
tl 


'Wl.,.||  .1 


I'H,    If     01 


•''•'i"''|l  withia  I 


liT,«i  (if  r,, 


■"»''•     Otln.r  .1 
^I'lration  ;   ,,s  l.y  ,,|,| 


'•y  rcmoii  of  (|; 


•lisfjisfs,   Ik, 

'"  vvliicli   till) 

asu« 

lililejfii, 


'•'^':'"';vi.i...i..k.:u:::; /;:;'':'•'!'•••! 


'"  '^•""•^"H   of  the   |,„a,| 


wliioh    1 1 


""',  <lix|.ei-se,|  al), 


loiU 


vvli 


>•'''«  «lt.o,..  I...  ir'      ""'"'"'•*'^  ..ttacksof 


""  >t  HSHuils  tl 


got    li.l  of,  ,„„|    ..  I 


I""'!'  wlio  an 


''itvs,  art'  not   j,,,' 


tllOHt  justly  cull,.,| 


'"■"'i-'  ■•"  allVctioi,   of 


"wak..  it  is  liani 


■'*«ver..,   |)„t 


O.'.l 


ici's,  t'\ 


<|i">'iilian  f 

t'lH  most 
"way  in  a  fi 


<'<Ns  of  (let,  ,, 


sacred  (w,>,7>„, 


a  MK  red  part. 


til  he 


18 


ever 


of 


it'iNt'N  a  coiKji 


''""'"f  than  either  (i 


»•'«(<•'•.   whieh 


'"■•""■'•'•)•"    Of  other  d'i 
">«»s  fever;   of  air, 


III 


'■•<  a   inoro  sliiu.rj.sl, 


'I'l 


and 


f.sy 


-■---»^™:r.i;;:t:.t:;;,;;,:i 


Id 


:oiir 


••I.Oloj^ry    „,     J.i 


P'-riod,  tha 


'  '»  in  a  qiiartaii  f 


|dlVsio|,|,ry    ), 


"to.  in  contrast  to  I 


lever. 


""•ee-lold  divj', 


'"astrai.jrelv  „„,d 


'l>l"'til.'.  represent 


""I   (>f  th. 


ind  int.)   re 


ItTII   Sil' 


'"sanato 
an. J  tl 


iruy 


ni/.MJ   I 


.V  .stnd.'iit.s  .,f  til 
'""""'■'al  prineipl..  of  tl 
•••■";""  ".la..)|s  in  „,„, 


■■*  ^''ry  iniieh  the 


■as. III.  u 


'10 


"H'titai  typ, 


ipirit  and 


l"<'sent  (lav.      'ij 


fi 


plant 


'""I  ''anil  to 


"''^'"''*arthlyl,„f„f|„ 


«   son  I   "tl 
an. I 


S   r<H,'0(r. 

'"'  rational. 


iii'ain. 


''«   ^'oldeii   eor.i  of 
'"a,siiiu(;h  as 


We  are 


iiiiTtal  souJ 
man  "  )ov 
'•''■ini.',s  of 


"nr  kiii.ire.l 


consists  of 


wl 


rais( 


es  a 


n.l  I 


two 


iniii;..rs  ami  tl 


avenly  ;rn,wth 
'"  •"•'-'    in  heaven.""  ""'i'j',„ 
''■''•'^i  the  one  with  which 


s  (18 

he 


y   oth-.p  ({..sire 


liir.s 


""''''■''^'  ""<!  the  l,o,„„| 


f«.  an.l  feels  the  (| 


SI. Ill 


,;''•  «pint,    is  .sitnate.1 


lary  of  tli 


's   place.!   bet 


<■  navel  ;  tl 


inidriir  and  ti 


n    the    I 


K'  oth 


iit- 
wi'i'n    the 


er, 


t'le  rnle  of 
and  r( 


''«'"'ck.  -inor-l.Ttl 


pas- 


ireast    lietween  tl 


■straini 


■t'ason  and  ,„i„ht 


i.'t  It  might  he  umi 


Wlllillir  of   th,.ir 


Hi,'   tin:  d 


J"i"  with  it 


ler 


i<'Mr.-s  when   tl 


i"c.)iitr.)||ii|, 


man.l 


N 


issuiiiij  from  tl 


-wn  ac(.n    to  o  e     tiJ;""   •;«  '""^"^ 

I...  fl,.>  „:..  ,    ,,.'">    ''"'  «'<)l«l  of   COM,. 


(>  more 


:ra[)h 


eita.iel 


•1   oni- 


£:;™:™'''»"^r;;;;,,!;s:;,:::':^ -•«*/.«.-«,, 


hen  .riven  tl 


lote. 


r  .Iriviiiir 


liaii   ill    ,|„; 


(Comparison  of 


"'  the  soul  i 


las  ever 


'*  pair  of  win.red  | 


'""I  of  nohie  bree.l 


ior.se 


tlio  oth 


"lan  to  a  ch; 
one  of  which  is 
and  of 


"t"  It'll. (I)|(. 


c, 


ij;iiol)le  breed,  so  that  "the  driving  of  them  of  iieces- 
bhy  1,'ives  a  great,  deal  of  trouble  to  liitu." 

The  comparison  of  the  mind  of  man  to  a  block  of 
wax,  "  which  is  of  dill'erent  sizes  in  different  men  ; 
harder,  moister  and  having  more  or  less  of  purity  in 
one  than  another,  and  in  some  of  an  intermediate  (]ual- 
it_v,"  is  one  of  the  hai)piest  of  Plato's  conceptions. 
This  wax  tablet  is  a  gift  of  Memory,  the  mother  of 
the  Muses;  "ami  when  we  wish  to  remember  any- 
thing which  we  have  seen,  or  lieard  or  tiiought  in  our 
own  minds,  we  hold  the  wax  to  the  perceptions  and 
thoughts,  and  in  that  material  receive  the  impression 
of  them  as  from  the  seal  of  a  ring;  and  that  we  re- 
member and  know  what  is  imprinted  as  long  as  tiie 
image  lasts;  but  when  the  image  is  effaced,  or  cannot 
be  taken,  then  we  forget  and  do  not  know."'' 

Another  especially  fortunate  comparison  is  that  of 
tlie  mind  to  an  aviary  which  is  gradually  occupied  bv 
different  kinds  of  birds,  which  correspond  to  the  var- 
ieties of  knowledge.  When  we  were  children  the 
aviary  was  empty,  and  as  we  grow  up  we  go  about 
'  catching  '  the  various  kinds  of  knowledge. 

Plato  recognizcil,  in  the  "  Timanis"  two  kinds  of 
mental  disease,  to  wit,  madness  and  ignorance,  lie 
has  the  notion  advocated  by  advanced  psychologists 
to-day,  that  much  of  the  [)revalent  vice  is  due  to  an  ill 
disjjosition  of  the  body,  and  is  involuntary;  "for  no 
man  is  voluntarily  bad  ;  but  the  bad  become  bad  by 
reason  of  ill  disposition  of  the  oody  and  bad  tuiucation, 
things  which  are  hateful  to  every  man,  and  hajipen  to 
him  against  his  will."  A  fuller  discussion  of  the 
ilieorem  that  madness  and  the  want  of  sense  are  the 
same  is  found  in  the  "  Alcibiades."  (II)  The  different 
kindf,  of  want  of  sense  are  very  graphically  described: 

Sitcratrs.  In  like  manner  men  <liffer  in  regard  to  want 
of  sense.  Tliosf?  wiio  are  most  out  of  their  wits  we  call 
"  madmen,"  while  we  term  those  who  are  less  far  gone 
"stupid,"  or  "idiotic,"  or  if  we  |)refer  gentle  language, 
describe  them  as  ••  romantic  "(ir  "  si!ni)li'-iiiiiideii,"or  again 
as  "innocent."  or  "  inexperienced,"  or  "  foolish."  Yon  nniv 
even  fiinl  ntlier  names  it  yon  seek  for  them,  hut  liy  all  of 
lliem  lack  of  sense  is  intended.  Thev  only  differ  as  iinc! 
art  appears  to  us  to  differ  from  anotlu'i-,  or  one  disease 
from  anotlier. 

There  is  a  shrewd  remark  in  the  "  Republic"  (VI, 
■I'Jl),  "that  the  most  gifted  minds,  when  they  are  ill- 
educated,  Itecome  pre-fminently  bad.  Do  not  great 
crimes  and  the  spirit  of  pure  evil  spring  out  of  a  ful- 
ness of  nature  ruiued  by  education   rather  than  from 

*  TheKtetus, 


I 


'''•^^^-'^^^-ra-ud  to  .ua";      '^    t'T''  "'  "'"  ''''i^i-t 
-  l"-»/;''ecy.  inspiration,   noe  ,       „  '^7 '"'"^  ^"•"-  '^''"'s 

^--^  '«  well  character!.  'i'  1  I'T  "•'"'  '"^^•"'"'  "H 
."'  "t  I'e  who,  havin.r.r  '"1  f  '"""^"'^'  sentence: 
'"  ''"*  '^""I.  comes  to\  e  r      "^"'"  ^^'"■^'^'«  '"'i'lness 

a"<i    18  nowhere  when  he  „  !  '"  ™''"'  '"h.'!  pears 

-•'-'"•-  certj;'ir^:'''^",'''-''':^iitha 

"^'^.•l  iis  -nanifestations  of,'  "■"  •'«'""t«lv  reco.r. 

'''^i'-eurahlecrinu  ;"^,tu  ,?r''  "  ""^  ""L-v.s'^" 
""Puise  which  uaoves  V  ,  V  ?''^''-'  "  0''.  ^ir,  the 
«;"''"ary  hun.an  Xh  noV"''  ''".'"•'*^'^  ''«  ""  " 
Heaven,  htu  a  ma.l  e  '  '  wS.  "i-f  .""^  visitation  of 
f'-o'u  Hnci«nt  and  nnexmaf^  ''"-"'''*"  '"    '"an 

"'"  "  Uw,s,"  too.  it  iria.M  '■'"■'  "*   '''-^  •■^'^*'-"     in 

'"••^'.""Ht.M^Mn  an  evil  an,r,,"ss InL  r"'"'  '""'  "^''^--^ 
are  .ne,e.se,l  l.y  ,,„,  e.iuc  t"  n  R  '^'"'^«'-'""«-'t.  an.l 
«f  ''enmne  it  i.  stated  h'  „.r'''"'''-  "'« --'are 
«'  'arge  in  the  city,  hut  hi     li  .     ^  ^'"r"'   '''«"   ""^  l>e 

::^;^o-r--'"-":-'K:t:t;!i.s-^^^ 

Fi-frir;;.;;;;: 'mention  of  disease  is  to 
^''e^eis  no  propor  ioT    ,    i    "    '"""!  **"•'  ''ody,  "  fo? 

'-at  hetween  soul  an,l  2v  -'      ^'V  "'"'   ^'^  '''a- 
"'  ^'"'.  '-in.  hein.  j  i"  j^     ''  ^  ' «  -loul.le  nature 

'"•Pa^Moned  soul   ..fore  powert   I  1  «"'"Pound  an 

?«"'.  I  «'*y,convulsesan  ms  .'  I'l"  I'  '""•'•  "  "'^' 
";'"''■"=""•■«  <'^'  -nan;  and  -I  en  ''''''''"'" '''''  ^^''"'^ 
of  .^onie  sort  of  learnin.  ,?   "'^'^"-  ■"  "'«  Pursuit 

"gam.  when  teachin..  or'^dil  ,  ; ;',  '''''■'''  ^"«'"'^' ;  or 
an.  considerations  1uHi3t'v'''''''"'^"'-'''M'nI.lic 
an.l  dissolves  the  cotnpo^t  ,  ,^'7  "''''''  ''"""•"«« 
''"ces  rheutns;  and   thi     ■  L,  T    """  =""'   "'tro- 

"ot  understood  l.y  ,noV  ir  X    '    ""J '''-"^menoa  is 
''-•''- it  to  the  4,pos      i  '  J:  "'■;  "'  medicine,  who 

""•'"'""'  «»'ould  1,0th   he  eo  ,' „     '     '"";^'^' iiody 

I'^'auKst  this  .iisproportion,'  I       , ';  jr'!'!'^-'  ^o  protect 
Kv  without  the  soul  or    hesl    v  '  T  '"''^«  "'« 

...v.,  ""-■'""' W'tl'out  the  hodv.      i„ 

ana  A^l I''''-",  "o Poeu  wrUe  poetry  buL  1  v 

-.ItK.logy.  J       ^'''"'''^'"'"'■tof  inspiration 


this  wiiv  they  will  be  ou  their  jjuard  uirainst  eacii  other, 
and  b(!iu'alihy  ami  well  l)alaiict'(l.'' "  lie  urijcs  the 
ujathi'iuaticiaii  to  piartise  ■jymiiastics,  and  the  i,'yinnast 
to  cultivate  music  and  lJllil()!^()|lily. 


Tht 


(ii's  of   treatment  advised  are  simple,  and  it 


is  evident  that  Plato  had  not  luuch  faith  in  medicines. 
Prfifessor  dovvett's  coinmeMtary  is  h(!re  worth  i)iu)ting: 
"  Plato  is  still  the  enemy  of  the  purjjative  treatment 
lysiciaiis.  which,  except  in  extreme  cases,  no  man 


of  j)h 

of  sense   will   evei 


(loot.      For,  as   he  aiids 


with  an 


insight  into  the  truth,  'eveiy  disease  is  akin  to  the 
nature  of  the  living  being  ami  is  only  irritated  by 
stimulants.'  lie  is  of  opinion  that  nature  should  he 
left  to  herself,  and  is  inclined  to  think  that  physicians 
vain  (c.  '  Laws,'  VI,  761  t',  where   he  says  tiiat 


are  in 
warm 


ball 


IS  would  l)e  more 


beiielicial   to  the   limbs  of 


the  ageil  rustic  than  the  prescriptions  of  a  not  over- 
wise  doctor).  If  he  seems  to  be  extreme  in  his  con- 
demnation of  luedicine  and  to  rely  too  much  ou  diet 
and  exercise,  he  might  appeal  to  nearly  all  the  best 
physicians  of  our  own  age  in  sup|)ort  of  his  opinions 
who  often  8|i(ak  to  their  patients  of  the  worthlessiiess 
ofdr 
and 


rugs.   l*or  we  ourselves  are  scepticitl  ahout  medicine, 


:;ry  ur 


illi 


to  submit   to  the   purgative  treat- 


ment of  physicians.  May  we  not  claim  for  Plato  aii 
auticipatioii  of  modern  ideiis  as  about  some  (piestions 
of  astronomy  and  physics,  so  also  about  medicine  ?  As 
in  the  'C'liarmides  '  (150,  7)  he  tells  us  that  the  body 
cannot  he  cured  without  the  soul,  so  in  the  •TiinaMis' 
he  strongly  asserts  the  sympathy  of  soul  and  body; 
any  defect  of  either  is  the  occasion  of  the  greatest  dis- 
cord and  disproportion  in  the  other.  Here,  too,  may  be 
a  presentiment  that  in  the  medicine  of  the  future  the 
interdependence  of  mind  and  body  will  be  more  fully 
recognized,  and   that  the  inlluence  of  the  one  over  the 


otl 


ler  may 


be 


ited   i 


n    a  manner  which  is  not   now 


thought  possible." 

The  elfecl  of  the  purgative  method  to  which  Plato  was 
80  op])osed   is   probably    referrecl   to    in   the   following 


pass 


When  a  man  jfoes  of  his  own   accord  to 


doctor's  shop  and  takes  medicine,  is  he  not  (juite  aware 
that  soon  and  for  many  days  afterwards,  he  will  be  in 
a  slate  of  body  which  he  would  rather  die  than  accept 
as  a  perniiiiient  condiiion  of  his  life  ''.  " 

It  is  somewhat  remaikable  that  nowhere  in  the 
"  Dialogues  "  is  any  reference  made  to  the  method  of 
healing  at  the  uE>culapian  temples.  The  comments 
ipon  physic  and   physicians  are  made  without  allusion 


tuth 


lese  institutions.  Hippocrates  and  other  practitioners 


"  Tiin:i'iia. 


If. 

co«co,ve.|  i.y  !>,„„.      w;  ;  •  '' '       'l'^''  '"' sonl.r,  as 

'""!•'«    "f    «.hut    was  iue  iCn    °;;""^  "'« greatest 
Pe'-'o'i  of  the  race,  wou  i    ,e  n       "^    '"  "'°^'  •"■'"'^"t 

'/'e'a.   which  i.,(lic.,te"!   ^    f  '""  "neruble  little   obiter 

-•''v:f''-"--'a;rw,iSr;;:;;  "^--'-^e  of  Z 

'"'^'^''-'HT.v  is  out  Of  ..oar  Tl  "  "  "l'/!'^'-'"".st  when  the 
charnun^.  analosies",ira\vn  fm  ,*!  '"■''','." '"'''■■"■o".  manj 
acute  su.,.e.s,io,?s.  .ome  o  ?  ,  T''"'""'  '""^  "'■■'"y 
ce..tur.v  flavor.  "1.^  'h  e  M  '"'  ,''"'°  ''  "in.teenth- 
-•-.-  Nestor^:,:  ^::';^'-'''"  wise  phvsiciau 
«>«".'  furnish  sonieof  the'  0  f  ,  ?"'  .'"'*">'  '»"-'''«•■ 
the  "  f)ialo^n:e8."  '°''  '"■''^'"g  iH-'strations  of 

M^ici,::!  Z';:,::^;:, ;;^';;';;;|;'^  .lefinitions  of  the  Art  of 

»v  Hch  consi.lers  theci.s  t  '"'T'/'''''  """«  '«  «"  A.t 
l"-".--l'i-  of  actio,  a  ,  'r  "  "::  •  ^'"  'T'""'^'  "'"'  '-« 
ag^iMi,  the  comprehens  1  vi  ,   '  '^'"'''  ™^«-"     Or, 

"  ^''"-re  is  one'science  of  ,r'l'  •'"''""  '"  "'«  «tate,„ent 
-•'•'  "-  inspect,' I'of  :  S"!  ^^'ir''  .■■«  -"cernei 
l"''j«pt.  past  and  futupe."  '^"''"•>'  '"  ""   tin'es, 

"'O''-!^  nle!iic?,.e''if'""'  "^^o-'-'t  of  the  origin  of  the 
Muildof  AscJepi'::'/^  '"'"■"''^''  -"'  tl.o  a^rt  of  tt 

"■'"l"  w..;;n!n,aMot',;;r7  ""^  ''"''•  "^  '"-"-'hs  -ct 

-  p.  have  b...n  ^^^^t^"^^^  ='  '"'''it  of  li?;^  S 

"'^"■'■"i-N  sons  of  AsHenius   o,  ,  "'''''  '-'"'"Pellin^r  ,|,e 

^';S  !'<•  said,   th,.v  do     i,   '•     ""'  "'"''  *oo,  a  dis-^raeeV 
"7;fangled  nan...s  , o  .itl"!"""^-  "'^   ->•  ^tranj^ri^^i 

<'"i<iicu,i,stnna.  that  ih..  I.       'l^     '••""'  ""»  '  infei'  fro, 
;  ;n-  (io„,,  of  areec.       "  ""     ^'"''"  "^  '''•""""a,,  wine  well 


10 


liesprinkliMl  witli  barlcy-mcal  and  (jratcd  clieosc,  wliicli  are 
cortijiily  iiilliiiiiinalor)-,  and  vet  tlie  sons  of  Asclr|iius  who 
wi'ic  al  llic  'I'njan  war  lio  not  lilanic  the  lianisel  who  givi's 
hull  _  he  ih-ink.cr  rcbiiku  Patrochis,  who  is  tn'alinir  hisra.se. 
Well,  lie  saiil,  that  was  snrclv  an  extraonlinai-r  drink  to 
bu  s^ivtMi  to  a  j)uiso.i  in  ids  condition. 

Not  so  cxlraordinarv,  I  rt-phcd,  if  you  hear  in  ininil  that 
in  former  days,  as  is  roinnioniy  said',  before  tlio  time  of 
Herodiens,  tlie  <ir„jld  of  AseU'jiii'i.s  did  not  practise  our  pre- 
sont  system  of  medicine,  which  may  lie  said  to  ediicaie  dis- 
cas  >.  Hut  Ilerodicns.  hi  injr  a  trainer,  and  Idmsclf  of  a 
sickly  constitution,  hy  aconihination  of  training  and  (h)ctor- 
in;,'  found  <jut  a  way  of  torturing  (irst  and  ciiicliv  himself, 
and  secondly  the  rest  of  the  world. 
How  was  that  ?  he  said. 

]i\  the  invention  of  linj^crinij  death;  for  Jieliad  a  mortal 
disease  which  Ic  pcrpetu.illy  tended,  and  as  recovery  was 
out  of  the  question,  he  passed  his  entire  life  as  a  valetudi- 
narian; lie  could  do  nolhin;,'  l)nt  attend  upon  himself,  and 
he  was  in  con.^tant  torment  whenever  he  departed  iti'anv- 
thing  from  his  usual  reiiimen,  and  sodving  hard,  hy  tlie 
help  of  science  he  strnj,"jl  ■(!  on  to  old  age. 
A  rare  reward  of  Ins  skill! 

He  goes  on  to  say  th.it  Asclepius  did  not  instruct 
his  descendants  in  valetiidiiiariaii  arts  becaise  lie  knew 
that  in  well-ordered  states  individuals  with  occupations 
hud  no  time  to  be  ill.  If  ii  carpenter  falls  sick,  he 
.«sks  the  doctor  for  a  "  rouKii  and  ready  cure  — an 
eineiic,  or  a  pur.ire,  or  a  cautery,  or  the  knife  — these 
arc  his  remedies."  Should  any  one  prescribe  for  him 
a  course  of  dietetics  and  tell  him  to  swathe  aiul  swad- 
dle his  head,  and  all  that  sort  of  tliinjr,  he  says,  "he 
sees  vo  good  in  a  life  spent  in  nursing  his  disease  to 
tlie  neglect  of  jiis  customary  employment  ;  and  tiiere- 
fore  bidding  goo  Ibye  to  lliis  sort  of  physician,  he  re- 
sumes his  ordinary  habits,  and  either  gets  well  and 
lives  and  does  his  business,  or.  if  his  constitution  fails, 
he  dies  and  has  no  more  trouble." 

He  is  more  iti  earnest  in  aiioiher  place  (••  (iorgias  ") 
in  an  account  of  the  relations  of  the  arts  of  medicine 
and  gymnastics:  "  The  soul  ami  the  body  being  two, 
have  two  arts  corresponding  to  them;  the're  is  the  art 
of  politics  attending  on  the  soul ;  and  another  art  at- 
tending on  the  body,  of  which  I  ktiow  no  specific  name, 
but  which  may  be  describeii  as  having  two  divisions! 
one  of  which  is  gymnastic,  and  the  other  snedicine! 
And  in  politics  there  is  a  legislative  part,  which 
answers  to  gymnastic,  as  justice  does  to  medicine  ;  and 
tliey  run  into  one  aimtlier,  justice  having  to  do  with 
the  same  subject  as  legislation,  and  medicine,  with  the 
same  subject  as  gymnastic,  yet  there  is  a  ditl'e'rence  be- 
tween  them.  .  .  .  Cookery  simulates  the  disiruige  oi 


11 


mp(i 


.S  '*"!,"« '^ookhu,! 


fft^^r  into  a   com 


•  tile  pli 


ju./m 


'.01-  tiieii  who  liHil 


Ij'et.tion  i„   wl.icl,  cl.iM 


l)est 
to 


<=     .  -■    ..H3M  WO  Mad    itn  ...  ■•-...     were 


t'in-s.  or    loa>l,   the  n| 


deati 

Ati.l  J 
be  th 
with 


»!'<ierstan,is  ,he   .00,1 


e  on 


■''«'•  '■"   the  same  dial 


""3-ia,.  wouh,  be^:;:";: 


re II    were    tlit 

ircti, 

iiess  or 

Ml   t 


o 


ilyt 


"■"<-'  politician  of  I 


OIT 


lie  Socrates  cl 


witli   any  vieiv  ^f     .  '  " 

Stare.  a,^.-^".°':'?'«««'"^.   h' 


'IIS  time  wl 


e.  iiiMl  is   unwiil 


'^'   hut  for  tht 


10   8 


i/H'ak.s 


'IIIUS  to 


not 


oric 


justice,      /[e  s 


aiKi  so  woi.M  m.,)j 


'"S  to  firactise  th 


«00(1    of   th 


avs; 


e  a  liad   (i,r 


e  graces  of  rhet- 


'  -^'lall    he  tried 


^''"•f  ill  a  court  of 


"'■•»  court  of  little  1), 


J'lst  as  a  ()hv 


'OV.S 


iit  tl 


'Sl- 

le  in- 


ci;tii  would  he  tried 

'S   tlie   death    of 
among  you,  cutt 


""gs  has  th 


accuse  hi 


m 


1.  sayinir,  >  f) 


you, 


|3  man  done  to 


n  a 
my 


fo 


costing  you,  until 


>>fi  and  bur 


especially  of  th. 


.Vou;  he 


.vou  k 


'"'"S  aiHl  starv 


youiiurer  ones 


IIIL' 


youthe'Gitt.:resrs„"!;:;r"'''f'-^«ri; 

an(  fast?     ir '  ..V  "'^'  •'"<'  comoe  s  r,,,.  .„   , 


fr")-f?  110.S 


m,,els  you  to  h 


::'"«''  I  procured  ;;;''r  '"^::'y  °/  ^eats  ami 


the  111 

th 

onl 


"'■you.'     Whatd 


luid  siif- 

ives 

liunger 

sweets 


.   P'l.vsiciau  would  rei.l'yw. /.'"[.'"" '"»'!'»««  that 
'«  P'vdioament .»     iCrif  ^"""''   ''■' "  ' 


y   say  :  ' 


in  self 


health,' and  tl 


'ciii  ,■-      i<or    f  lio  .   1  1    .      '-"use  I   1 

'^''thls,,:;U^';'',;-^n'thhecou[ 
fl.a..    „.-    ,  ;    ,"•>"'  '    'ii'l    with    .1    .,; 


amoii"'' 
'i'h'r 


'leii   would  th 


siii;h  iud.resP     it         ,     '"^'  J"st  be  a  cl 
>._•     JV"'-^-      How  thev  i.,^..i.i  _  ^'. 


(1 

a  view  to 


Pn'nciple  of  con 


t'ley  would 


cry  out] 


lamour 


-'"■«''.  like  the  .i!xrj::\'''"'^''7''^  to'\r  '"■'• 


Several  strik 


found.     '1' 


111^'  passages  ill 


'vus  conceived  of 


body 
as  a   ^./liole 


think  th 
«t'i'tly    witi 


i-to-the;,uestio;;:rfc^j;'---'>e 


J'hied 
that  tl 


»! -■•»»-««;.. ;r.:--;jM_,„„ 


"lit  kno 
rus  replies,  "  I J 


"i,'  th 


is  the  onl 


"^^^'"•^  -en  of  the'bX  ;;  Z 


'«:  the  nature  of  th 
'PPocrates,   the    AscI 


fwrtaiice  of  tre; 


X5":'f.'™s„rK:;,'s 


le  whole.'" 
ipiad, 


sifted  upon.     I„    th 


a'l'i;^,'  the  whoit 


e  case  of  a 


"ii'ierstood. 
and  not  the 


'I'h 


lie 
le  iui- 


""'"'  with  bad  eves  theL     "*  f!^''"*'"^  vvho  com 
cure  hl«  «..„„  1...^*^*  '"<'  sayinur    «  .,  .i,,.^  .i.„. 


-tire  Ins  eyes  h.-  »i.  ,    "".""S  li 

be  cured     .'      L '"^'"^«'^«^«'  l»ut  tl, 


th: 


I'ed  his  head 


'S  is  "  that  th 


part  is  ill. 
les  to 


^>;  «ay  "  that  to  think  of 


must  be  treated 


liat  if  hi 


cy  cannot 
♦^yes  are  to 


and  then  a^ai 


''••^!''«'--' of  the  ij;  ^Lo';;^^''^  ';ead  alone  an^ 
•V.^".'^."'ebei.rhtoff,.llv" 


cvS'ti'-i'-r-™.-: 


folly. 


could  cure  him  of 


'"'lich  he  h.Ki  J 


one  of  the 


't.     fie 

•■"•'It,  uhe 


"crates   to 


;::";:?.:!^?':-j-'-:ai.ci 


make  bel 


leve 


"ai'l  that  he  had 


that  he 


iX'ysicians  of  the  Th 


n  serving  with   tl 


nh 


iiru!. 


"■acian  kino- 


lie  army,  of 


O' 


Zamol 


xis. 


12 


Tills  ])liysici;iti  had  told  Socrates  tliut  the  cure  of  the 
part  should  not  be  attempted  without  treatment  of  the 
whole,  and  also  that  no  attempt  should  be  made  to  cure 
the  body  witiiout  the  soul,  "and,  therefore,  if  the  iiead 
and  body  are  to  be  well  you  must  Ijej^in  by  curing  tlie 
soul ;  that  is  the  first  thing.  .  .  .  And  he  who  taught 
me  the  cure  and  the  charm  added  a  sjiecial  direction, 
'  Let  no  one,'  he  said,  '  persuade  you  to  cure  his  heiid 
until  he  has  lirst  given  you  iiis  soul  to  be  cured.  For 
this,'  lie  said,  '  is  the  great  error  of  our  day  in  the 
treatment  of  the  human  body,  that  physicians  separate 
the  soul  from  the  body.' "  The  charms  to  which  he 
referred  were  fair  words  by  which  temperance  was  im- 
planted in  the  soul. 

Though  a  contemporary,  Hippocrates  is  only  once 
again  referred  to  in  the  "  Dialogues  "  —  where  the 
young  IIip|)0crate8,  son  of  Apollodoruj,  who  has  come 
to  Protagoras,  "that  almighty  wise  man,"  as  Socrates 
terms  him  in  another  i)lace,  to  learn  the  science  and 
knowledge  of  human  life,  is  asked  by  Socrates,  "  If 
you  were  going  to  Hippocrates,  the  Coau,  the  Ascle- 
piad,  and  were  about  to  give  him  your  money,  and 
some  one  said  to  you,  '  As  being  what,  do  you  give 
money  to  your  namesake,  Iii|)pocrates,  O  Hippocrates,' 
what  would  you  answer  ?  "  "I  should  say,"  he  re- 
j)licd,  "  that  I  give  money  to  him  as  a  physician." 
"And  what  will  he  make  of  you?"  "A  physician," 
ho  said  —  a  paragraph  which  would  indicate  that  Hip- 
j)Ocrates  was  in  the  habit  of  taking  pupils  and  teach- 
ing them  the  ait  of  medicine;  and  in  the  "Eutli\de- 
mus,"  with  reference  to  the  education  of  physicians, 
Socrates  says,  "  that  he  would  send  such  to  those  who 
profess  the  art,  and  to  those  who  demand  payment  for 
teaching  the  art,  and  profess  to  teach  it  to  any  one  who 
will  come  and  learn." 

We  get  a  glimpse  of  the  method  of  diagnosis,  de- 
rived doubtless  from  personal  observation,  possibly  of 
the  great  Hippocrates  liimself,  whose  critical  knowl- 
edge of  pulmonary  complaints  we  daily  recognize  in 
the  use  of  his  name  in  association  with  the  cliilibed  lin- 
gers of  })hthisis,  and  with  the  succussion  splash  of  pneu- 
mo-thorax.  "  Sup[)Ose  some  one,  who  is  incjuiring  into 
the  health  or  some  other  bodily  (piality  of  another  :  he 
looks  at  his  face  and  at  the  tips  of  his  fingers,  and 
then  he  says,  '  Uncover  your  chest  and  back  to  me 
that  I  may  have  a  better  view.'  "  An(i  then  Socrates 
says  to  Protagoras,  "  Uncover  your  mind  to  me;  re- 
veal your  opinion,  etc." 

One  of  the  most  celebrated  medical  passages  is  that 
iu  which  Socrates  professes  the  art  of  a  midwife  prac- 


i;i 


tisiii.r  on  tl 


"titli  or  will 


'";  s"'<l8  of  men  when  tl 


""II,  tlioni.l 


ifii-  condition,  uli,nl 
■■^oiiif  "(lailin^r  t\,l 


I'fy  are  in  la 


iilior.  and 
"''■  I'lvynant  with  the 


'  'on;:,  nnisi  i 


dill 


)<■  ( 


ii-'Mliies 


jiK-ted. 
'tiid   wish 


Jl 


i«  t^iitire  sec- 


f'l'criites  i,s 


III  one 


^';.-.Th...tetns.whrhau":::::::'".!'^"T.«'^^'- 


l>'iniH;on  ot'  I 


owled^re    |,„,   be^J 


'i;arning,and  whos. 


't'en  iiresenteil  to  1 


mil  as  a 


silentl 


I 


lik 


e  a    nv( 


II  sure  and 


l>'%M'e«s  in  the  ,,ath  of 


iiiooth   ••  (low 


feel 


"f'<'tetus  is  sooi 


rot    0,1   •__,„,,,   .^    ^,^^^^,, 


iiii;    on 


iiiir  of 


iiiixi( 


ty- 


t'litan-led  and 


t'dj^'e 
cannot  shake  olf 


Thiiri.     J 


ver 


3<'ii ;  hia  J 


ciin  assin-e  v 


>■  often,  when   I  ) 


answer  to  .rj 


•an  neith 


liiMi-d  the 


■oij.  SoeraU's,  tliat  I    1 


<l"e>tioMs  whiel 


would  liave  Ml 


^ive,  noi'  hear  ot 


''I'  Pi'i-^iiade  nnself  that   1    | 


liive   trie<| 
li  eanii-  from 


to  an,' 


wer. 


L'  answer:  and  I 


">■  one   who  aiLswe 


liave  any 


etus 


>'/f. 


'I'huse 
;  yon  have 
'"g  K)  the  hirth 


(•annot  -et  rid  of  the  .1 


•IS  as  you 


esMe 


'»'c    the  pane's  of  1 


onieth 


iig  witliin 


iihor,  niv  d 


'l^heM.     \  ,1 


yoii  which' 


oar  'I'lii 


yoii  are 


www 


'\nd  did  , 
"'"  of  a  midwife,  b 


'' !"'t  know,  Socrates;   I 


arete  'i 
Snc. 


M>ii  never  liear.  S 
I'ave  and  I 


only  say  what  I  feel. 


tun 


•"•'•     Yes,  J  1 


"'i|'li:t„n.tl,at  1  am  tl 
i}>  wliose   name  was  I'h 


;en- 


So,:      I 


■^'I'i  that  I  njvself 


»ve  liearil  that. 


A'.),  I 


never 


practise  midwife 


lieard  that. 


yon  nnist  nut 


•«'  nie  tell  ytn,  that  I  ,1 


not  found  m 


it'Veal  the  secret 


1 


Wit.* 


am  an  exceed 


II'  out:  ami 


n 


end 
ecet. 


III! 


"Ah'  f'ti 


thoii^li, 

IS  the  woi'M 

V  oulv 


•yV 
my  fi-iend  ;  h 


lit 


you  ever  hear  tl 


tlicrefore  the 
\""^  beilin-,  „:ho  d 


in  <;eneral  hav( 
'iiy  of  me,  that 


'lat ; 


I  ive  men  to  the 


ir 


'■^'>c.     Shall  I  tdl  vo„  ,1 


yyntet.      H 


] 


y  al 


must  mak 


meau.s 


le  reason 


""il'^-ive.s,  and  the 

"(iman, 

eoiiceive 


•■  yjii  Icfstand  tl 


as  you  an 


11  you  wil 


'i;t!  my  meaning-  1 


!>'  situation  of  th. 


wl 


and 


l';>ai-e  j.a.st  he 


oear, 


l>i-olialily  aware,  wl 


letter. 


T/h- 


■ctl. 


ilriiii;-. 


intends  othei 


llO     IS 


iihle  to 


Tl 


iroiide; 


^^'s,  I  know, 
ic  i-cason  of  till 


women,  but  only   tho. 


wl 


of 


oliildbijth i 


■•'i'id  to  he  that  A 


rtemis 


lo  are 


like 


'■"■i'''ii  to  be  miihv 


"'  mystery  of 

iissio,,,.,"!  ,1 


IVes,  I 


'•■■"elf;  but  si 


"■  ^"giii,  and    she   1 


'ceaii.-t; 


:iii   art  withou 


!»■  eiiuld   iiDt 
inmaii  nature  oa 


I'llff    llCiirilirr,    1 


is  oil 


lii'e  to  tl 


t  e.xperiei 


honors 

allow  tile 

iinot  knii  V 


iiose  who  bv  n 


and   thcief 


Ore 


n, 


'Wl. 


■Jl 


lononn^.  tben,  from  theii'lil, 


■•'iisoii  ol  ai,'e  are 


'■*''"'■.     And 


I'lt  is  natural 


Heness  to  herself. 


that  tl 


a  naiiira, 


ami  who  i 


!'•  midwives  k 


.  or  rather  n 


not  ? 


now  better  tl 


lece.' 


'lan  uihcrs  w'l 


ry  iiifereiu 


J  llHL 

!Soc 


'•      V'ery  true 
And  by  the 


use  of  jiut 


lo  IS  jircgnant 


on.s  and  incantations  th. 


I 


It 


re  iililc  to  iirtmsi'  the  inm<;s  and  to  soothe  them  at  will 


tluM-  can  lua 


ki'  I 


lo-^e  hear  who  ha\ c  a  ilillieultv  in  hearii 


ami  if  liiev  clioose,  lhi'\  can  smother  tliu  iialie  in  the  wonih. 


Thr 


Dhl  V 


on  ever  reiniirk  that  lliey  aie  also  most  enn- 
nint:  inatehtnakers,  ami  have  an  entire  knowledge  of  wiiat 
nnions  an!  likely  to  proilnee  a  hrave  brood  Y 


Th, 


u:t. 


I 


never  neait 


I  of  tiiis. 


rid 


Then  let  nie  tell  vim  that  this  is    their  greatest 


e,  more  than  eiittim 


till 


hilieal  eoid.     And  if  von 


reflect,  you  will  see  that  the  same  art  which  cidtivates  and 
U'ailicrs  in  the  frnits  of  the  earth,  will  In-  most  likelv  to 
know  in  what  soils  the  several  jdants  or  seeds  shonld   he 


I'jiositeil 
'J'/iml. 


es,  the  same  art. 


And  do  yon  siipjiose  that  this  is  otherwise  in  the 


case  or  women. 


n 


'lllVl. 


I.     No,  that  is  not  likely. 

No,  indeed;  hut  tin;  midwives,  who  are  respeet- 
ahle  women  and  have  a  character  to  lose,  avoid  this  dejiart- 
nient  of  practice,  because  they  are  afraid  of  bein'i  called  pro- 
cnre-ses,  which  is  a  name  yiven  to  those  who  join  toifelher 
man  and  woman  in  an  nidawfnl  ami  nnscientilio  wav;  and 
yet  the  true  midwife  is  also  the  true  and  oidy  matchmaker. 


ThuEi.     That  I  understand 


S«,d 


I  are  the 


mid 


wives,  whose 


work 


IS  a  very  im- 


jiortant  one,  but  not  so  important  as  mine;  for  women  do 
not  l.iini;  into  the  world  at  (nie  time  real  childreti,  and  at 
aiiiither  time  idols  which  are  with  dilliculty  di>tini,'uishe(l 
from  them;  if  they  did,  then  the  disceruim^nt  of  the  true 
and  false  hii  th  wonlil  he  the  crowninu  achievement  of  the 
art  of  nddwifcrv  —  yon  should  think  uf  that? 


Tliiat.     Ves,  I  ccrtii 


should. 


\V( 


mv  iirt  of  mi 


iwif 


theirs;  but  the  dilfeience  lies  in  tl 
and   not  w(jmei 


cry  IS  in  most  respticts  like 


iis- 


-tliat   I   attend 


men 


are  in 


my  art  is   in 
mind  of  the  yi 


id   I   practise  on   their  souls  when  they 

labor,  and  not  on  their  bodies  ;  and  the  triinnpb  of 

in;r  whether  the  thon<;lit  which  the 


(iol  or  a  iiolile  and  true  creatic 


man  is  brin^'ini'  to  the  birth,  is  a  falst 


I 


iini  liarren,  am 


Itl 


And  like  the  midwives. 


iroach  which  is  often  made 


me,  that  I  ask  (piestions  of  others  ami  have  not  tl 


tl 


lem   mvse 


If, 


J' 


aijainst 

rs  ami  liave  not  tlie  wit  to 

st ;  the   reas(ui   is,  that  tlie 

god  compels  me  to  be  a  midwife,  but  forbids  me  to  l)rini' 

forth.     And  therefore   I    am  not  myself  wise,  nor  have   1 

my  own 
lose  who  converse 


anvthin'j;  which  is  the  invention  or  oilsprin"  of 


soul,  but  the  way  is  this  :  —  iSonie  of  those  wd 
with  mc,  at  lii  si  appear  to  be  absolutely  dull,  yet  aftei'wards, 
as  oiir  acquaiuiance  rijiens,  if  the  uod  is  gracious  to  them, 
they  all 'if  them  maki!  astonishing  progress ;  and  this  not 
only  in  their  own  opinion  but  in  that  of  others.  There  is 
)f  that  they  had   never  learned  anything  of  me, 


but  tl 


ley  Jiavi!  accpiircil 


cliscovere{ 


1  m; 


my  uolile 


of  themselves,  ahnoiigh  the  god  and  I  help  td  dt 


And 


)f  is,  that 


if  tl 


th 
•th 


attributing  all  to  themselves  and  despising  me.  either  o 
their  own  accord  or  at  the  instigation  of  others,  liave  "one 


em. 

lem  in   their  ignorance, 

)f 


I 


"way  sooner  tlian  tl 


tlu'v  I 


T  I'fiyt!  i.nxliii.,.,]  i',1 


15 


•iiiiiiicai 
tiiiin    |,y 


IKII.S 

itn  il 


i.rl 


inioi].'. 


•e  re.siili  I,„,,  been  fliat 


"■';■''  lo.xt  (II,.  cliil 


y  reason  of  t| 


"I'^i-ti  viiliie  (lian  t 


"■■'"A'lv^  i,|,,  ,i 


'  "I  whidi  I  (I 


II'"'  •■Vil  COM! 


'Iivcrt'd 


illir  tl 


nil 


ic'nselvi..s,  as  oti 


I  ;  iind  (licv  i 


\;:r'^'i--''>'-io;;;::; 


icrs 


y*iiiiii(,'liiis,  is 


''<lfs.  tlie  son  oV  / 
»'■«■  Miiuiy  otlitTs.    'ri 
tliat  I  ■  " 

<JO  (|, 

,,,  "."^  iin!  case 


■'<•<:  tlicni,  to  I 


"•'^''  fir  last  end,.,!  I 


'II!  threat  foiil.s.  ',\,,j,( 


would  conveis,;  will,', I 

'"<••'"«  not  alwavstl 
"'■<>w  asiiin.     /)i 


!""  triiiinis  often  rt-t 


/K'of  this  sort,  and' ti 


>»'iii  a>,'ain-    tli( 


I'ni  lo  Ml,!,  and  I 


lejr 


Ir 


then,    if 


niv  f 


ii':oiise  and  to  allav  in  tl 


IK^ 


t'Cfivt'tlic 

|)iln!,'S  willed 


>nrt'  ready  to 
iuniiiar  allows, 
iiiid  tlicv  I 


>^<'in 


""'■  jiiNt  like  tl 


<lav  tl 


t-y  are  full  of 


P'lnjis  of  ivonien  i 


I'lwe  who  have  int 


'  "'V  firt  is  all 


i"  childhirtl 


••fcoiiise  with 


wor.se  than  that  of 


are  otI 


("•■•plexity  and   travail  wi 


'; '  'liglit  and 


notli 


'"•'•H,  'Iheii't. 


iiij;  in  th 


woni 
*"S  who  ( 


'">■  art,  I  coax   tl 
of  (iod  J 


!«'"';  and  as  I  k 


ioiiiucli 
o'lie  to  me 


uril 


tieiii. 


Iiit'h  is  ev_. 
And  there 


en 


'"'"'  into  anoihe 


"""'  that  thev  I 


ai>[)areiiliv  hav 


inir 


■y  liave  no  need  (,f 


race 


V'  ''0<1  I  fan  .'radnalK"     ,,'"  ,"•''■.  "'""".  and  hv  the  \r 

;;!'-•   inspired  .s^^gc^.-T     ,"  ToVtl' '■".'""'■^'  ""•'  -'" 
Ihea'teiiiu    I „.."   .  ''-"  3011    this   Onir    .»,„...    <■  _  ■ 


if«''eiu.s,  hecaiisc  I 


yourself,   t| 


tion. 

a  inidwift 


'at  you  are  in  hihor 


yo'<   tills   k. 
s.'isi'ect,  as  indeed 


'onie  then  to 


ood. 

"S  and  some  to 

11.'    ftory,  friend 

you  seem  lo  think 


and  t 


nil 


ly  t 


'.who  am  a  niid 


vat  with  som 


II'  confer 


yo;;-     And  if  I  ahsi 


o  answer  the  iiii 


;^'te  and  the  son  ot 


I  (1 


liscovcr  I 


have  fi 


'■act  and  expose  vonrfi 


d'O'i  insjieciion  that  If 


'•-^"011  which  I  will  ask 


rvt-1 


'■n.  Iieeaiise 


that 
cliild 


«i«  a  vain  shado.::,irnr:;;:i:!r. :!!!''■''  3- 


aceoiint,  as  tl 


rcn  are  (aken  fn  »  tl 


'''  "lanner  of  woine 


o  not  (juarrel  witi 


ou 
I  nie  on 


some  who  we 


I'e  re  a 


ily  to  h 


lein.     l.'„r  I  I 


«  when  their  first 


'lave  acliialh 


viiown 


';'"«:« Mi;,".;;:'^;;,^:;"*"  !,'''ri~i'^"™ 


;'ood  will,  not  k 


(that 


nowiiiK  'liat 


I   11 


was  not  within  tl 


;;ot  ^.erceive  ihat'  I   acted  / 
no  i-oil  IS  tl 


"t-'r  enemy  in   all  :his,  | 


in^je  of  tl 

t)iit  reli.n, 


'II 

edi^e 


leir  id 
ill 


"le  enemy  of  n 


'0111 

nan 


neither  was 


wuuns/  repeat    n,y  „,,i 


If  truth.     (), 


vonr.self  lik 


'"111  lio  not 


*av  ih 


ipifstion,  "  What 


Iff  inure,  t 


yon   cannot  tell  •    | 


is    k 


len, 
Mnwl- 


)Ut 


fiiit 


you  will   be 


.•■'uiseii  iiKe   a  man    •.,.,!    1        1       ,     " "nuoi    Ic 
able  to  tfll.il  '  •*'"'  ^y  '''«  ''«ll'  of  (iod 

'-"^'•h  into  the  wo  7  ,  'n  "'";,  ^^'f'  vou  have 
l""!'^  •-..„  aroutj  the  1  ear  1     vj^  1  T  '"'   ''"'"    ^^« 

'«'«  worth  rearin.  or  .vTt;" '*''''''•''"  ^^''''^''^t- 
^  I'e  to  be  reared  i7.  a  i^i^e v  !  '"  1^'  '""'  ''  ^''-"• 
'"•"  rejected  and  uot  .Jiin  o  .l  "' *'.'^'  >T  ^'''*''  '"  ^e« 
yuur  /irst-boni  ?  "     'J^.e  '       ,    '•'*'".""  '^  '  ''^^e  away 

'"■"."^''-t  forth  witid,  a,  M ;;  "r"  ';'■""''  -^"^  '-■' 

'•'•--'- "Ot  worth'hr^in'^^'ir '^«:;;'';f  "V""'- 

•  niwutetus.  =     -^      !■         -I. Hi    the  dialogue 


Ifi 

cikIh  as  it  ln'niiii  w  iih  n  reft>r<Mic«  to  the  nii(iwit'e  :  "  The 
>Hii'i'  ot' ii  iiiiilwitc   1,  like  my   iiKillicr,  huvc  icccivcd 


from  (fod  ;   nhc  dclivt  iid 
lint  tlii'V  must  he  ',  u 


woiiifii,  and    1  d«"liver 
I  i-.i 


mull  ; 


iKililc,  mid  tun 


iir. 


From  th<^  writini.'^  of   Plato  we  mav  "iithnr 


details  al/diit,   the  status  of  [iliysiciaiis  in   liis  tiiiie. 

is  vei-y  evident  tliat  tli('  |irolession  was  fur  advanced 


many 

it 


aiK 


I    had    lieeii    iproj;iessivel_v  deve!()|ii 
period  liefore  Hijiiiocratt's,  wIkiiii   we 


11.' 


for 


Willi  a  certain   iirdjiriety.  call  tlie  Fut/icr  of  Mnli 
The  little  liv-|ilay   between  Suerates  and    i'jill 
HU;rj,'i'sts  an  advanced  condition  of  medical    lit 


Of 


ercdiieoMslv,  vet 


cine. 
lydeimiN 
(•rature  : 


(Miiirse,   von   who  have  so  iimiiy  hooks  are  iroini 
III  for  l)eiiij,'a  doctor,'   .says  Socrates,  and  then  he^ulds 


there  are  so  many   books  on   mediciji 


As  Dyv 


e,  voii   k 


now. 


er  remarks,  whatever  the  iiiiality  of  these  hookn 


may  have  been,  their  number  must  have  1 


give  |ioiiit  to  this  cha 


ir. 


leeii  great  to 


It 


ly    be    clearly  gathered  from   tli 


e  writings  of 


rialo    that, two  sorts  of  |(liysiciaiis   (ajiart  ultogKl 
from    (|iiack8   and    the  JO^culapian  guild)   existT'fl 


At! 


Atlieiis,  the  private   practitioner,  and   the  State-pli\> 


ciaii.      The  latter,  tlioiii'li  il 


le  smaller  ii 


iiniencally,  rep. 


resenting    apparently    the    most    <iistiiii;iiished "  d 


'  rom  a  reterence  in  o 


ne  of  the  dialogues  (••  Gorgias  ") 
they  evidently  wer'  elected  by  publicassemblv.—"  when 
the  assembly  meets  to  elect  a  physician."  '  Tl 


uis  apparently  yearly,  for  in  tl 


marl' 


n  the  \  ea 


Slat 


le  odico 


r  of 


•'small      is  the  it 


or  physician  lias  to  come  befor 

answer  any  charges  that  may   be  mad 

III  tl 

one 


has  expired,  the  admiral 
e  a  court  of  review  "  to 


e  against  him. 


le  same  dialogue  occurs  the  remark,  "and  if 
who  is  ill  a  private  station   has  the  art   to  ad 


one  of  the  public  physicians,  n,iist  1 
physician  ^ ' 


any- 

vise 

le   not  lie  called  a 


Apparently  a  physician  must  liav 


III  practice  for  some  time  and  attained  great  e 
before  he  was  deemed  worthy  of  th 


If 


you  and  I  were  physicians,  and 


iieeii 

minenct! 

e  post  of  State-physi- 


were  advis- 


ing one  another  that  we  were  competent  to  pract 


state-physicians,  slu.iild    I  not  ask 


ise  as 


not  ask  me.  Well,  but  how  about  Socrates  1 


you,  and  would  you 


le  good  healtli 


And 


was  any  one  else  ever  ki 


iimself,  has 


be  cured  by  him  whether  slave  or  fr 


lowu  to 


A  ref 


eemaii , 


ereiice  to  the  two  sorts  of  doctors  is  also  found 


ill  the  "  Republic 


(inr);iii 


Now  you  know  that  when  pa- 


tioiifs,?otiot  m, 


llrldtT    H    , 


17 


•I. 


■•'«""''ii.   the    i„c 


"'Veil,  tUi't,  tli,,  ,1 


•Mior 


lave  „„Iv  to  I; 


""«•' ;  l.iit  wl 


■'*""  of  |)ra"(:ti 


•«  {Hit 


'lOllt'l'     JH 


two 


'i'iio  oil 


'"•«  <•«•  Stai,,.,,|,, 


I'J*-"'"!-   iJldlllij    I 


"'11  iiKMlicine  |,,t,  to 


'"  niori)  ot  H  III 


Ull. 


tl 


.«'--^aio..,.:;;:.!Ti;r;-:'"r.-.-i--.r 


''"*  {'"fit  lit  Atl 


llllv 


tiir\ 
proi' 


"'"«  ill  III. 


Z'Z'J:^ '!-:-'*' >:Z 


r"  ««»>»:;  ^^r'l.i'r'';-''-''-'''--!-; 


of  S, 
tlie  (i 


''"'*'"•  "'i-lit  l,t.,  I 


and. 


\«TV   III  lie] 


■»  «reat  ii,crt-a 


aiiios 


It 


8e 


"«  was  s,.,luo,;j 


ll  Ct!Il- 

'   as  a  iiiodiTii 


ill  salai  V  liv  po| 


avvav  by  tli 


'"  ''vi-l-i.t,  too.'lVoin'tIi 


•^'-•'"'••^l'a.las,si.s,a„t.;„;. 


.Vcratfs,  til.,  t 


(!r 


tie 


10  ()/}■ 
yraiit 


gfiitl. 


''"',"■  o{   .Joe 


a.sk  111,.  ,1 


it;i-,  oiIiiTs 


to 


rs,   as   I 
a  111(1 


■''"  '"«""^'  tiiii  Slav 


'"vs,"  that 


may   I'fiiiind  y 


't.'8. 


'I'Kislafur  to 
What  I 


'wior   to  |„ 


tors' surv 


iiican  I 


'■"'•<■  <Jiir  ,i,s„r,i 


'•I'  im'thiiil  of 
villi   tl 


K'-iiti 


I'lIM 


"11,    SOIIIC     hav.!     j 

■""'  as  childri., 


ay  i.s,  I 


li'i-s  Willi  tl 
liat  hcsi.le.s  ,|oc 


10 


"^iv  trill.  ■- *'>''»-'d  doctors. 

I'^'^i'if^  and  olie,  .;','!''•■  ''■''"^'^'JS"  of 


i'';ai  so  we  will  ask  ,| 
*'"'  ^'••ntl.'st   ie,i„.dies. 
are  d 


to -s  thfie 


(JU- 


di/r 


:''/'•     And 


HffOrdl,|;r    l^,   fj 


>eivii,,r  tl 


III'  natural  w 


o   ilii'ir  iiiastei 


-r^-vh::,;;;;-i:-^;:^v'n™,,,j 


art  wliich  i| 


'a^'y  inipar 


Siiei 


ai-e  aware  that  tl 

A//i.     , 
f  f  I'atient 


w:  sure. 


lere  ai 


'''iiiun  makes  no 

'.'I  nieilieiinj  hv 

'j"'l"ri.Mllv  and  not 

"'  niaiiiier  of 

i^t'lves  the 


iti/ii.MlU-  them 


'"Sti;^;;;'';";ri:"«..,v:; 


'\  111  did 

'■»  in   st 


! Of tors  ? 


.)•""  ever  observe  that  tl; 


tl 
till 


oeioi-s  run  ahi 


;iie 


III'  di; 


I'cnsaries 


at  and  cure  tl 


■■^'aves  and  fi 


d  ^r,  r:'::^--'-- 


'■''""■";  and   the   .s| 


slaves,  or 


I'aiiints  iii,|.:.il| 


'ii-'iitioners  of  tl 


wait   lor  tl 


"iiiividiial  eoniol 

litiit'..    .  » 


naliv 


IIU'l 


•-*  t"-''lH'ii(ii 


tin 


l«y     'Jhe   si 


Irt  tl 


n's  sort  n 


live 
ii'ni  in 


'"■'a  talk  about  tl 


I'ver  talk 


ave-doetor 


(0 

airown 


^''!''^vh-;,XSt.asifi:i;:;,i 

o'»ui  iii.s  orders,  lik 


I'i'eseriljes  wl 


oil  witi 


and 


fi/nal 


^o  he  r 


assurance  t 


o   some  othe 


I  I'xact  k 
•-'  a  t\  rant,  I 


lat 


now! 


'i»- 


I'  rushes 


^--n;c  master  .:r.h::'T:r--^''--'i 


''>■'  iavali,!  slaves!     JJ 


:ilteii 


and 


l"-acti>e,« 


int  ll, 


^;''|airi..sfarl,ack,aml 


lie  eii.er? 


'^  ot'a'r  doctor,  wl 
■••""•a;  and  | 


njion   h 


liaise   of  th< 
o  is  a  f 


tare  of 
'•L'enian, 


■■■*     "Ito    d,,S( 


1^  t'ariies   his 


"■nils,  and   is  at 


our, 


;.;;.";»,«,,„.  ,„;,,:x;;;;, 


■«-•    with    tl 


"am,  and  also  i 


""'■i'  H'-niu^  iufo, 


I'aiaiit    and  will 


iistruclin"'  1 


,;;"  -f  l-c.cril,e  for 
;    '■'■^'',».^''<^aliehas   h 


'a  as  far  as  1 


■Illation  fr 


aiiiler  I 


iiai  until  he  hash 


he  is  ah 


nn  till 


ii  Ills 
sick 


''-  and  he 


bet 


■alth.  1 


I'l-'isnasive  inll 


■"ii-ht   the   1 


'•■-t  convinced  I 


''^  aiieniot.. 


''•'•  "-av  of  ,,r,„.,;,,, 


lo    c/f, 


n.-iici 


and 


is  he  (I 

or  he  wl 


'It  a  cii 


aticnt  nio 

"'■<-  J'ini  on  Ihe   n.aii 


an 


ic  b 


aMvoiksi 


la.tr  in  a  n| 


re 


is  al 


'liiti  idea  of  li 


"■"r''  '^''"  accon,,,  N,  ?; 

"'^"''«av,andlhattl 


''y-'i'ian  and 


'""  'vhich   is  tl 


in  a  tra 


Hill  ; 

more 

to 

'le 


laidsiii  ad 
'a'lndcraMd  iu'f 


Ollll, 


Ulrr  ' 

I'  wav, 
erior '; 


so  iiieiiti 


rst  ( 


indeed  to   i 


'"lied  ii,  th(!  >•  ( 
"'inched   o. 


■""^■'■"'•'■"ir  a,.aii..,itl 


'    .'laVe  1 


ioi'i;ia> 


and  U( 


■•-''liiation    for  s 


'V  ar;L;iluieiit 

a/i|)ear 

oiue   of   the 


18 


niitiiiTDiiH  HOpliixfA  nf    thitf.  |)i>rinil.       Ciorjjiim  landiiit^ 
tilt)    viriiit'H  i/f    I'lii'idi'ii-    :iii(i  flititiiiiiir  tliiit  itlic  IiiiMh 
iiiiili';'  licr  HWiiy  all   llm   iiit'crior  iirt,  muvh  :   "  Lt't  iiio 
olfcr    yiiu    u   Nlrikin^   uxiitupio    of    this.     On  Hovenil 
orcusioim  I   liiivo  been  witli  my  hrotlmr  lluroiliciis,  or 
HOIIH'  otlitT  pliysiciaii,  to  see  oiio  of  liix  paiientH,  who 
would  not  allow  tlio  physician  to  ^ivu  liini  iiuMJiciiit)  or 
apply  tilt!  kiiift'  tir  hot  iron  to  liiiii :  i'.iid   I   havt;  per- 
Nuiitlt'ii  liiiii  tti  tlo  for  lilt)  what  lit)  woiiltl  not  do  for  tim 
pliysit'iaii  jiiHt  hy  the  list)  of  rlititoric.      Aiiti   I  say  tl'i't 
if  a  rhftoriciaii  ami  a  physician  wero  to  go  to  any  city 
and  liati  tiit^re  to  arguu  in  tliu   KcclfBia  or  any  other 
asMfiiilily  as  to  which  of  tlitMii  shonlti  he  flfcted  tttate- 
lihyNiciaii,  the  physician   vvt)uld   have  lit)  clianct;;   h'.it 
he  who  coiilil  speak  wtiiild  ht)  chosen  if  he  wish,"      Jii 
another  plact)  ("  haws")  I'lato  hatiri/es   this  custom: 
'•  For  of  this  you  may  be  very  sure,   that  if  one  of 
those  empirical  physicians,  who  practise  inetlicint)  with- 
out science,  were  ti>  come  iiptiii  ihe^entleiiian  physician 
talking   to  his   j;eiitle  patient,  and  iisinj,'  thi)  lani;uai;e 
almost  of  [thilosophy  —  be^^imiinjj  at  the  hi'j;iriiiiiiir  of 
tilt!  tiisease,  anil  tliscoiirsing  about  the  whole  nature  of 
the  botly,  he  vvoultl  hurst    into  a  hearty  lau;;h  —  lie 
wouiti  say  what  most  of  those  who  are  calletl  tloctonn 
always  have  at  their  toiiirue's  eiul  :   foolish   fellow,  he 
would  say,  you  art;  not  liealini,'  the  sick  man,  but  you 
are  t'ilucaiiii<r  him  ;  and  he  tloes  not  want  to  be  made 
a  iloctor,  but  to  jiet  well." 

Of  tile  [lersonal  cpialilications  of  the  piiysiciin  not 
much  is  said  ;  but  in  the  '•  Uepnblic"  (III,  -lOSi  there 
is  an  orijjiiial,  aiitl  to  us  not  very  agreeable,  ilea : 
'•  Now  thf  most  skilful  pliysieians  are  those  wlm,  from 
their  youth  upwards,  have  comliinetl  with  a  kiiowledne 
of  their  art,  the  i.'realest  experien  .■  of  ilisiMse;  they 
had  better  not  be  in  robust  iiealth,  and  should  have  lia'd 
all  manner  of  diseases  in  tiieir  own  [lersoii.  For  the 
hotly,  as  I  conceive,  is  not  the  iiistiumeiit  with  which 
they  cure  the  body;  in  that  case  we  coulil  not  allow 
them  to  be  or  to  have  been  sickly  :  but  they  cure  the 
botiy  with  the  iniiiil,  and  the  miuil  which  bus  ln'come 
and  is  sick  can  cure  nothiiii;." 

Some  itiea  of  the  estimate  whieli  I'lato  put  on  tlie 
physician  may  be  irathired  Iroiii  the  mvsiitial  aeconiit 
III  the  "  I'hii'ilnis  "  of  the  iialuit!  of  tlif  soul  and  of  life 
in  llin  upper  woriil.  We  art-  but  animateil  failures  — 
the  residua  of  the  souls  abtive  wliit'h  have  attained  a 
vision  oi  truth,  Imt  have  fallen  "hence  beneath  the 
double  loail  of  forjjetfuliiess  anil  vice."  There  are 
nine  ;;ratles  of  human  exi-^tence  into  which  these  souU 
may  pass,  from   tliat  of  a  philosopher  or  artist  to  that 


1!) 


ilg 


'""'.  to.,,  01,  t|„.  ,i,|,.  J(  ,      ""'""  '"  "'.V  art."      We  li.Ml 

•"ay  be   lo.«iVen  i„p\  ;,•    /''■^''''■^'''•'  '"  •'•'-..k  ,„„,|. 
co„i-|,  „iv,.„  1,^,  Krvxi,n„,.l.,.      •  '"'''^••''•'/"•"nH    for  l.ic. 

^'f '«"-.  wii..,.  ti;^:  :^  7:^";:  ^r'-''"i'u...j.,  to  ti^ 

;«teM  too  „,„oh  a„,i  l.,u     t  ,  I.         ''V""**  "'*""^  ''«  ''■"' 

"  '  ""  «ater,  u.„l  if  ^  )J  .'"''"''  '"  -'"'W'"  »vith 
''^■'^'-  '"•«  "ose  with  L  ^tU^'J'  ^""  «<>'"i"u.'.l.  t^ 
you  si.,,02c' once o,-  tvvic  !.  ^,  '  '""'■""'  «'''"">(.  "if 
'«  M.re  to  ^ro.-         '^"''-'"^vxM.  'I'e  most  violent  i.,eeough 

ralll,''''!'  ?'""'"''■'•''' ^V'"(.tom,s,.a,.r.,,, 

,""'  ;'^a„k  tl.e  poi«„.  ;,i';^;''  '•;•■•  "'.•.•  Socrates 
•well;     but  I  „,,v   ref,r  ,  •        "  "'""'Ce-^'arv  to 

;  "  ^-.'renee  fdt  "^ o r      , .  'r,,;;r  T'^'  -^  '■"'"'■a-.i..g 

^V'.'  «ays  that  ,1..,,.  i,  .  ,    "^      ,7"'""'-'"f  tl...  jailor. 

•<  "to.  woowearo,.L  to    V       .       •""-   ^"'•''«    Were, 

^f.-.u  to  |,e.-  accorilin.  ,o  I)  "'    ?  '  "^  ■^"''•'•"'^'«  ^''-l-l 

''";■•"•  ■«  •"■'-.ife.t  in   tl.  i     i '-   '"'"""^  ""•'  *-''ose 

1'^";-  'V'.'l  "M.le,l  all  ,l.e  .     "J '^^  ^'"'^''   '-•"'•-I   all   the 
'"-•1^%  wh.oh  cured  l.i,,.  of   i  evv^.l '^"'"V"'^  "  "'«  ^^^'^u 

--■'^=.n.g„Horeail.fe«ocrate:c;iv:';:S 


20 

lapius  a  tliank  offeriMi.^  This  olFering  of  a  cock  to 
vK-iculupius  was  plainly  intended  for  liim  as  the  awak- 
ener  of  th€.  dead  to  lite  everlastinir." 

And  permit  me  to  conclude  this  already  too  !on<>- 
account  with  the  euloijium  of  Professor  Jovvett  — 
words  worthy  of  tiie  master,  worthy  of  his  great  inter- 
preter to  this  generation  : 

'•  More  than  two  thousan<l  two  hundred  years  have 
passed  away  since  he  returned  to  tiie  place  of  Apollo 
and  the  Muses.     Yet  the  echo  of  his  words  continues 
to  he  heard  among  men,  because  of  all  philosophers  he 
has  the  n)ost  melodious    voice.       He   is   the   inspired 
prophet  or  teacher  who  can  never  die,  tlie  only  one  in 
whom  the  outward  form  adecjuately  rejiresentsthe  fair 
soul  within  ;  iu  whom  the  thoughts  of  all  who  went 
before  him  are  reflected  and  of  all  who  come  after  him 
are  partly  anticip.ited.      Other  teachers  of   philoso.ohy 
are  dried  u{)aii<l  withered, — after  a  few  centuries  they 
have  iiecome  dust ;   but  he  is  fresh  and  bloominir,  and  is 
always  begetting  new  ideas  in  the  minds  of  men?    Tiiey 
are  one-sided  and  abstract ;  but  he  has  many  siiies  of 
wisdom.     Nor  is  he  always  consistent  with    himself, 
because  he  is  always  moving  onward,  and   knows  that 
there  are  many  more  things  in  philosophy  than  can  be 
expressed  in  words,  and  that  truth  is  greater  than  con- 
sistency.    He  who  approaches  him  in  the  most  reverent 
spirit  shall  reap  most  of  the  fruits  of  his  wisdom  ;   he 
who  reads  him  by  the   light  of  ancient  commentators 
will  have  the  least  understaniling  of  him. 

'•  We  may  see  him  with  the  eye  of  the  mind  in  the 
groves  of  the  Academy,  or  on  the  banks  of  the  Ilissus, 
or  in  the  streets  of  Athens,  alone  or  walkin<r  with 
Socrates,  full  of  these  thoughts  which  have  since  be- 
come the  common  possession  of  mankind.  Or  we  may 
cninpare  him  to  a  statue  hi<l  away  in  some  temple  of 
Zfiis  or  Apollo,  no  longer  existing  on  earth,  a  statue 
which  has  a  look  as  of  the  God  himself.  Or  we  may 
once  more  imagine  him  following  in  another  state  of 
being  the  great  company  of  heaven  which  he  beheld 
of  old  in  a  vision  (•  Pluedrus,'  248).  So,  'partly  tri- 
(litig  but  with  a  degree  of  seriousness'  ('Symposium  ' 
]'.'7,  K),  we  liiiirer  around  the  memory  of  a  world 
which  has  passed  away  (•  Phaidrus,'  250."  C)." 


■O- 


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i  Physician  In  Plato's  RepnWlc.-The  Lancet  has  the 
.ow.ng  scholarly  note  that  reveals  the  mind  of  the  great 

lortii  To't" '°rr''"^^''^  ^^^^"^°^  medicine?;; 

[own  t  me.  To  those  of  the  profession  who  are  interested  in 
histonc  reflections,  it  will  be  pleasing  to  note  that  Pla  o 
Rave  precedence  to  the  physician,  empirical  t  ougl  he  It 
ihant -'"?:•  pI::  '"  r^^^^^^^^y  theologian  or  •..tiero- 
^rnT  H  ,        '  '"^^■'"^  ^^^  ''^"^^^^  that  embrace  the 

artist  the  ruler  and  the  merchant  were  those  who  stood 
supenor  to  the  physician.  The  physician  stooa  fmrth  t  a 
ras'sle  in'Se  Tr    '''"  '"'"'''  ^-^^^    "InTctiou 

Sfu^i^Co  1  c1,e""hy?rer^of1l''"^H''''''?«"--*'- 
transmigration  of  souls     Tl  p  I^n     i-^\'\  ^^ctrine  of  the 

- ,  the  second  degree  shall  be  «  liJ  f  ""'^''t ''"'  *"««"  •'•"^''  "> 
the'scale-is'tt  «'  "'''^'/^  ^°'he  Kda  ,'  'w  '°?  ""^,  "'"« 

s-^^r-^i^^^^eS^iliiB^^r^^'^- 

hierophant  .-re"''"^'  ""^ever.^o  findlharthe  .f^'^P^^^i" 
profeLionii,'5faced"p"'  '^i^'^^^^t^tiveVar,  Cnlf ''f 
parativelvlowoif        ^^''"  lower— viz    fifth  "p,'™Po«ant 

J;«ieultt  iTde^rS.  ^:,i'-  P^^T  "'-S'°'- i-ot 

mmmmm 

w?thouT  Vi  r''  profession,  may  read  f'hr°.'  "^'^  """s'-  «••«  • 

mBmmmm 

C  "  ~ "V  ''''-''^  'eal  med,>„i  ^p'  ^.ji"^''  chicanery  with  a 

-  ■■■aittT  or  wonder  thatThn  n^M    ^'f '  ^"'^  ''-  can  hardlv 

.  uch  pretenders."  '^^  Philosopher  looked  askance 


,     -"T""'l        III I    I  'i      .      ,-  , 

^^^>i*-./t„i(uj   <j„i    'jsujnq   ouu-;ur    SirJS'x'*'  'I 


lira  FOR  Tin 

YEARS  WITH  RiC 
IIILEIiHEilRT 

Wonderful  Case  of  Harry 
B.  Travers.  a  Lawyer  of 
St.  Thomas,  Ont.,  Whose 
Death  Has  Just  Oc- 
curred in  That  City. 

FHYSICIANwS  OF  TWO 

CONTINENTS  FUZZLED 


(By  Special  Wire  to  The  Courier.) 
St.  Thnmas,  Mttj-  13.— Harry  B.  Trav- 
ers, a  barrister,  ulio  died  suddenly  In 
the  Amos  A.  Wood  Hospital  and  whose 
funeral  took  place  on  Sunday  with 
military  honors  and  six  brother  law- 
yers acting  as  pallbearers,  had  a  most 
eventful  career.  His  phypleal  condi- 
tion as  well  had  been  a  puzzle  to  the 
leading  physicans  of  two  continents. 

Mr.  Traver.s  was  a  son  of  Mayor 
Travers  a  former  governor  of  the 
Isle  of  Malta  and  came  from  a  long 
'line  of  officers  In  the  British  Army. 
He  was  born  in  Ciwion  Ifi  years  ago 
and  come  to  St.  Thomas  vi  licii  a  young 
man.  Here  he  studied  law  and  being 
called  to  the  bar  entered  into  partnei- 
shlp  with  ,Iohn  Farley,  K.  C.  He 
served  several  years  in  the  city  coun- 
cil and  took  a  prominent  part  in  nubile 
affairs.  His  uile,  a  daughter  of  his 
former  partner,  iiredeceased  him  f.ev- 
eral  years  ago  and  he  leaves  two 
daughters. 

Origin  of  the  Wound 
_  When   a   lad    playing    tennis   on    his 

:i^i~:l.-j 1 , — , 111!  I    l-iiiiilli,      I   m.liii  ii.nl. 


'  'ffi'o   .11    J 


|m    Hklgeto 

npany    win 

forty   tho 

•IT.      B.      '. 

oma,s,    who 

nadian   com 

been    alio 

i)tlf   fund   o) 

liiontly     cMr. 

Ini  an  aneur 

|'r.cna   Grov 

St  If,  wa.s  th 

jilly  a.s.sault 

ceerling   .,.; 


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"il^any    will    „ay    o 
forty   thousand  i 

,i"t'ntly     disabled  '     h/  '"*^  J"^''- 

ini  an  aneurism  oi  (|,e  h\LT,^'''''"'< 

8tip,   was  tho  vioJm"   '.f  V'^'^as    do- , 
dly  assault  Sundlv  niiu  '"«,"'  "^^-L"," 


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iLieFOBilIlfiTY 
YHfiS  WITH  BIC 
f  IN  HEAIIT 


Wonderful  Case  of  harry 
B.  Travers,  a  Lawyer  of 
St.  Thomas.  Ont.,  Whose 
Death  Has  Just  Oc- 
curred in  That  City. 


PHYSICIANS  OF  TWO 

CONTINENTS  PUZZLED 


(By  SpetMnI  Wire  to  Tlu'  covirler.) 
St.  Thomnji.  Mny  Kl.— Harry  B.  Trav- 
ei'.«.  a  harri.'^tt'r.  who  riled  smldonly  in 
tlic  AniOH  A.  Wofiil  MnapttMl  inid  whose 
fun*'i'nl  took  placi*  on  Sniitlity  with 
military  linnors  und  six  brnduT  liiw- 
ypr.s  actintt:  as  palllifartTH.  Iiui)  a  nioHt 
ovontful  rart't'c.  IM^  [ih.\  sloal  coinll- 
tlnn  as  vvt-ll  h;Mi  hoeu  a  |ni/.zle  to  the 
U-adlng   phy.slcfiii.s  of   two  .-ontlrn'nts. 

Mr.  'rravti>  whs  u  Hi*\}  of  Mayor 
Travel's,  a  foriiu-i-  K<>v«inor  r»f  the 
l.sU;  (tf  Malta  alul  raine  110:11  h  lonif 
lin**  of  oflicfrs  in  the  Hritinh  Army. 
He  was  born  in  t'rvlon  fi>  >(-arH  ago 
and  conu'  to  st.  Thomas  wlH'n  a  young 
man.  Hitc  he  Htudhd  law  and  ht'lng 
callod  to  tlif"  hai"  cnleriMl  into  partner- 
Rhlp  with  John  Parli-y.  K.  (\  He 
served  .several  yi-ars  in  tiic  flty  eoiin- 
cH  and  took  a  prominent  part  in  nubile 
affair.'*.  HIb  w  Up.  a  duuKhter  of  hla 
f<n-mor  r'»rtner,  prrdeceased  him  lev- 
eral  years  ago  and  he  leavea  two' 
daught'TP. 

Origin   of   the  Wound 
Wli'M    a    lad    playlnr    tennis    on    f-^f 
fatlur-H    e.Htate    near     Dublin,     Ir^li.Wj^ 
in   runnlnjr  after  a   bait  he  ran  ovpr  a 
short    terrace   and    falling,    a    pencil    in 
his    upper    waistcoat    piMkft    entoie-i 


THE  LATE  H.  B.  TRAVERS 


I  WhoHe  heart  wrs  pimctured  by  a  fall 
when  a  youth,  but  he  was  able  to 
lead  a  life  of  groat  activity  for  ovei 
thirty  years. 

|!iIr  Ride  near  the  shoulder.  The 
I  wound  l,,^Hled  up  and  nothiUR  more 
I  was  thruiBlit  of  It,  until  about  1!>  sears 

2.iro.     '-v.iiT,     h."     n-,;*,'!.-     n  j-i'it'sitOtt     ht'n? 

for  life  iuHunince  and  v,us  rejected  by 
[the  Miedlcal  examiner  who  found  that 
I  he  was  mifferlnj?  from  a  large  aneu- 
I  rlsm. 

Other  physlelans  in  the  elty  and  else-  I 
where     after    examinations     ,  onflr.ned  | 
thiB    (liflKnosIs    and    gave    him     hut    a 
Hhort  time  to  live.     He  went  to  I,onilon, 
Kngland   and   was  examined    Sir    ••'"red- 


lerlck 


ireeve.i,     Dr.     Mcf'ormli-k 


and 


I  other    celebrated     rihysleiiiiH    and    

iKcons    who   gave    him    but    nix    ioonihs 
I  to   live.     HIh   case    being   of  Huoh    long  f 
'"taiidlm,-    ooaslnned     ( onslderable    In- 
j|nMi     and    eomment      n    the    medical 
uilH  at  the  time.  ,  H  who  exa^nlned 


H-t.o«e  Mean    wh«  ,„„a.tureri   hy   „    rail  I 


jhi!< 


I    fc     ho     «,'''''■'■   '""'but   Hix    ..,onth»| 


■fo 


;iiiiini!  I  i[  Hill 


r 


.    m    1 .1  ..II1.J.  1    11    ijip   ,„mr    .Wffll'Si 

■j.inoa.i  nipiiloal  rprnrrts.  Aftpr  his  r  ■ 
-i.Jii  to  th,.  city,  Mr.  Travprs  nngaifpii 
in  hoxlne,  hasohiill,  (TU'kot  and  ln"vn 
tonnls  Hrid  thoiisti  at  tlmrs  In  the  mlrt- 
rtlp  (if  Ihf  Raiiic  lio  rxiK'tlenrnd  a 
"lipart  burn"  ho  wnuM  finish  ns  fi-esh 
and  api.aipntly  as  upM  as  thp  hpal<h- 
|p.«t  of  his  .-onipatilons. 

Too  Much  for  Osier. 

On  two  riiffpront  occasions  somo 
foiirli'PM  anri  sjxtppn  ypars  ago  hp 
went  t"  niiill.iiorp  at  thp  rprpipst  of 
Dr.  osier  and  Dr.  Halstrad  ami  was 
put  under  a  tlioniugh  examination  >,nrt 


a  loral  physican  like  "an  pnginp  piimp- 
Ing  slpani." 

Wlu'ii  tli'^  Ilnpr  war  brol<p  out  he 
was  in  l':iit;laiid  and  liP  retvirnpd  lo 
Montreal  jusl  aa  the  llrst  Canadian 
lontiMKpnl  was  about  to  leave  for 
.South  .\  I  ilea  Up  sueepeded*  in  bping 
pDidlleil  ii.'i  a  private  and  went  throuRii 
tile  (ampaiRn  ultli  liLs  eoTnrade.i,  tak- 
InK  pari  in  the  buttle  of  Paardolierg 
and  tlie  eapture  of  Oen.  t'ronje. 

He  returned  at  Hie  close  of  the  war. 
but  did  not  reHiinip  his  practice,  his 
condition  being  .such  and  the  pain  so 
Kreat  that  he  had  to  remain  as  quiet 
as  po.ssible  and  uhp  stimulants  to  re- 
llpve  it.  However,  he  made  no  coiu- 
lilaint.s  and  borp  his  sufferliiKS  wltli 
pril  and  pluck  for  wlilcli  lie  was  noteil 
and  wlilch  no  douM  had  much  to  do 
with  the  prolonninf,'  ol  liis  lile  in  the 
j  condition  in  wliich  he  was.  Four  or 
five  months  ago  he  was  altackcd  with 
dropsy,  a  result  of  the  aueurisin,  and 
his  end  came  suddenly. 

Heart  Has  Been   Removed 

Dr.    Osier,   after   exaiiiiniiiK   Mr.    Tia- 
vis,  expressed  a  deslrp  Ifi  see  his  heai't 
I  after    death,    and    that    desire    may    l)e 
i   gratified,  as  the  heart  was  removed  liy 
i   Drs.  Gray  and   Enin  of  tliis  city,   who 
propose  to  send   it   to   Ixmdon   or  New 
York   in   the   Interests   of   medical   sci- 
ence.     The    organ    was    found      to    be 
three   times  larger  than   normal   and   a 
dilation    of    the    aotra    as    Uukp    as    a 
walnut    was   found    as    a    result    of    the 
puncture   of   the    ppnal.     The   mark    of 
the  woumi   of  the   pencil   is   still    (luite 
perceptible. 

"There  was  nothing  on  earth,"  said 
a  medical  inan  to  The  Courier  corre- 
spondent, "that  kept  Travrr.';  aiivc 
but  stimplants,  and  liow  lie  could  be 
kept  alive  for  over  thirty  years  Is 
marvplnus  and  breaks  all  records  tn 
medical  annals." 


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WEBSTER,  N.Y.  14580 

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CASE   OF    ARTKRIO-VKNOUS    ANEURISM    OV    THE 

AXILLARY  ARTERY  AND  VITN  OF  I-OUR- 

TEEN   YEARS'   DURATION. 

Bv  WILLIAM  OSLER,  M.  D., 


PROI-KSSOR  01.M,s|,IClM.:   JOHNS  HOPKINS     r  NI  VKRSI  TV.    AM 

.|0!l\s  HOI'KINS  HOil'IlAI.. 


1   I'HV.iMIAN  INCHn;i--     TO 


THE  following  case  is  worth  placiii-   on   record,  partlx-  on 
account  of  its  rarity,  but  more  particularly  on  account  of 
the  lonnr   duration   without  serious   symptoms    and   the 
admirable  illustration  which  it  aflhrds  of  the  proprietv  of  non- 
-intervention in  certain  instances  of  aneurismal  varix. 

On  December  28,  1888,  I  saw  in   Hamilton,  Out.,  with    Dr 
Malloch,  H.  B.  T.,a£,rcd  twenty-fwe,  who  presented  the  following 
condition  :    He   is  a   stron^^r,  healthy  younc.  man,  with  a   fresh 
complexior ,  well  developed  muscles  and  a  well-shaped  thorax 

I,tspcction.~1hc  apex  beat  of  the  heart  is  in  the  fifth  inter- 
space inside  the  nipple  line.  There  is  a  slioht  fulness  beneath 
the  outer  half  of  the  left  infra-clavicuL.-  space,  and  pulsation  is 
seen  in  this  re-ion  ;  there  is  also  slight,  but  not  nearly  such 
marked,  sub-clavicular  impulse  on  the  right  side.  The  carotids 
do  not  throb  visibly,  but  on  the  left  side  above  the  clavicle 
there  is  fullness  in  the  lower  cervical  triangle,  and  a  distinct  im- 
pulse. The  position  and  appearance  of  the  left  clavicle  are  nor- 
mal. It  ,s  not  elevated.  There  is  perhaps  slight  fulness  in  the 
hrst  intercostal  space,  near  the  sternum  ;  there  is  no  special 
prominence  of  the  first  rib,  or  of  the  manubrium  sterni. 

Palpation. -T\x^  cardiac  impulse  at  the  apex  has  moderate 
force  ;  there  is  no  thrill.  There  is  no  impulse  upon  the  sternum 
or  beneath  the  inner  half  of  the  left  infra  clavicular  region' 
1  here  IS  a  very  distinct  impulse  in  the  prominence  above 
referred  to  in  the  outer  half,  upon  the  clavicie  itself,  and  upon 
the  sub-clavicular  fulness.  There  is  a  continuon.  ^■ibratorv 
thnll  communicated  to  the  hand,   which    is   felt  over  the  whole 


I.; 


'•? 


I 


"^  iiy/././.i.v  <>.s/./:a>, 

rc-ir,nofpi,lsatinn,anclthe   entire    Idt   side  of  tl.e   n.nt  of  the 
neck.      Il  ,.  not  felt  on  the  ri-rht  side,  nor  over  tlie  sterninn.  nor 
on  the  pr.ecordia.     Tliere  is   no  definite  t,mmr  to  be  felt  either 
below  or  above   the  clavicle;    the  enlaroenients  referred  to  are 
sr.lt.  and  y.eld  readdy  to  pressure.      Ili^h  up  in  the  axilla  there 
IS  a  fulness  m  the  course  of  tlie  artery.     To   tlie   touch    it  does 
not  -ive  the  sensation  of  a  <listinct  tumor;   there  is  a  ren,arkai)le 
cunt.nuou.s  thrill  in  this  re-ion  which    is  obliterated  here  and  in 
tiK-  subclavian  region   when   tlie  axillary  arterv  is  conipressed 
Ihe    left  arm   looks   normal,   the  veins    are  not   distended,  the 
hn^e,-.na>ls  are  neither  blue  nor  incurved,  and  the  tips   are  not 
clubbed.     The  pulse  in  the  left  radial   is   not   so  stron;,^  as  in  the 
rii,d)t ;  there  is  no  perceptible  retardation. 

/Vmm/.w.-The  cardiac  dullness  is  normal.  Percussion 
over  the  manubrium  and  on  the  inner  half  of  the  infra-clavicu'ar 
region  is  clear;  the  outer  half  is  distinctly  resonant. 

A;LU-u/taf/o;;.-Thc  heart  sounds  are  clear  at  apex  and  base 
Iherc  IS  no  special  accentuation  of  the  aortic  second  sound  •  no 
murmur  in  the  ri-ht  ■        .d.  or  in  the  ri.^dit  sub-clavian  arte'ries 
Over  the  outer  half  ot  the  left  infra-clavicular  area,  on  the  corrcs- 
pondingr  portion  of  the  clavicle,  over  the  lower  cervical  trian<de 
from    the    sterno-mastoid    bord>;r    to    the     attachment    of    Sie 
trapezius  there  is  a  loud  continuous  /?nat.     This  murmur  is  also 
heard  with  great  intensity  in  the  axilla,  down  the  inner  surface  of 
the  arm,  and  on  the  front  and  back  of  the  fore-arm      It  is  very 
loud  and  distinct  in  the  palm   of  the  hand  and  in  the  finger  tips 
In  all  of  these  regions  the  murmur  resembles  an  intense  finaV  dc 
diablc,  or  a  venous  hum  at  the  root  of  the  neck.     At  one  point 
only,  just  below  the  clavicle,  there  is  a  slight  systolic  intensifica- 
tion of  the  murmur.      Posteriorly  the  bruit  is   heard  in  the  sub- 
scapular .space  and  feebly  upon  the  scapula    Subsequently,  when 
the  patient  came  under  my  care  in  Philadelphia,  he  was  seen  by 
Professor  Ashhurst,  who  noticed  that  pressure  upon  the  axillary 
artery  high  up  in  the  arm-pit  caused  complete  disappearance  U 
the  thrill  and  the  murmur  in  the  clavicular   region.     The  diag- 
nosis of  arterio-venous  aneurism  was  made. 

The  history  of  the  patient  is  as  fallows  :  When  fifteen  years 
of  age  in  running  cown  a  sloping  grass  plot  he  fell  and  forced  a 
lead  pencil.  wh.r>   was  in  his  watch  [x^cket,  into  his  side  higli  up 


t 


'      '    '/  '  /v'/.S.!/ 

'"  t'lc'  axilla       \y\  1 

■*  "c  niust  carpfni  , 

ITnr    .  "^ 'T-'ii.  notJnno  should 

^-"I  quarters  n   ^  T""''^'  '"^"^  ^^'^■'•e  -sou-^ht  .  ""'  '"^ 

at  all  bv  ni      r  '      '^  ^°™^^'- statin.r  tlntl.T      ■   ,        '■^'  ^"^'nsclled 

nn,„,ca,i„,,  _,  '">"-  and  b.,o„  „,,  ^i^.^oV;--. 

'  'lave  heard  from  ,1.,  -^ 

-■f  '-  co,„i„„e,,  „.e„,    ""'^  ''■''"™'   "">".  .).e  la.st  si.  ,„„„„, 

'-*-:r'°L;;;::r---..a,,d  .,.,,,,„ 

"-Aiiaustive  artirif-    /r 


WIII.IAM  n-  /./.A'. 


beck's  Archiv.  Btl.  33;  was  able  to  collect  only  ten  cases.      In 
several  of  these  the  condition  lasted  for  a  long  time  ;  in  one  five  ; 
another  seven  ;    and  in  a  third  thirty-three  years.     In  the  latter' 
after  persi.stin-  for  all  this  len-th  of  time  without  anything  ,„ore' 
tiian  sh-ht  painful  sensations  in  the  fin-ers,the  left  arm  increased 
in  volume,  became  u.'dematous,  and  the  veins  were  distended  a 
condition  which  necessitated   lif,ration  of  the  sub-clavian  artery. 
In  this  case  the  lead  i)encil,  in  all  probability,  perforated  tl'ie 
artery  and  vein  hiyh  up  in  the  axilla,  and  it  is  evident  that  the 
openin-  is  in   the  a.xillary  artery,  and   not  in  the  sub-clavian 
for  the  thrill  and  pulsation  above  and  below  the  clavicle  disap- 
pear when  this  vessel  is  compressed  hi-h   in  the  arm-pit      The 
remarkable    thrill    and  fullness    in  the  sub-clavian  trianyle  and 
the  sub-clavian  space  is   associated  probably  with  distei^sion  of 
the  sub-clavian  vein  and  its  branches.      An  intercstinc,^  point  in 
the  purring  murmur  was   its  intense  transmission   to'  the   peri- 
pheral vessels,  and  it  could   be  heard   loudly  even  in  the  fin-er 
tips-  ,  ^ 


^r 


ten  cases.     In 

.' ;  in  one  five  ; 

III  the  latter, 

mytliiiif:!;  niore 

arm  increased 

e  distended,  a 

:lavian  artery. 

perforated  the 

idcnt  t!iat  the 

L'  sub-clavian, 

clavicle  disap- 

uni-pit.      The 

triangle  and 

distension  of 

itiiig  point  in 

to  the    peri- 

in  the  finjjer 


''''"■'"'"'/' TuK  l'„AnTr,ox„, 


C  Jtx  v/,K 


™'   <'"'«'N.O    INTEmnTTENT    FEVER 
OF   ENDOCARDITIS. 


^ 


™'  ^'HRONIC-  INTKR.MJTTKNT  FFVFR  OV 

'J'HK  type  of  cnilocarditis  elmractorUn  I  k 

;""' -  i".e,u,a..  intennitto  rtn  sY'^  '^'""^'^''   — 

Tl'o  paroxysms  .„ay  l^iu^^    ::'''l  '^^  ^'^  ^'-onbo.l  • 

'I'l'^-   quotidian    typo   is  L    .\  '""'  '^'  ^''«  f^'^^'''- 

-casionallybeend  scrL.       ..  r      ''""'"""'    '^''    '''^^^^^    ^^'-^ 

■■;■»-'■  D.-.  Bo^d'^'o  °i:;::,;e ';*:.;;::.;■; -■-•■'■■  -«""" 

eliiomc  valvular  diso..se   witl,  Jnt!/.  '""'"'  '"^^''^''^^  «f 

"""'f''^.     I"  a  re,narkal,t  .o.   7       ^  ''   ^''"''^^    Jastod  four 

«;■«  o.»,„,.  «eu:;fc  r:::^^^^^^^  ^'.^■■-  "'f  ■'•'•""■"« 

i-Mances,  tl,o   existence    'i  !"''■''"  "f'">»"  <lise.se.     J„  so„,e 


i 


I 


I 


III 
I 


4  ■/'///■;  <iii!n\ic  i\ rr.inii rrrxr  ri:\i:n 

liiluiv;  sii  also   with   iinc   ..I'  J.i'V.U'ii's  rasfs.'      |!iit    i\\v   hk.m 
cxtriiuKliiiary  niso  of  tlio  kiii.l  i>  roconk'd  by  Dr.  Uiistowo.-     A 
piititMit  liHil  nguo  in  ()ct,(jkT,  with  chills  nun.  ,„•  twice  a  ilay,  in 
iin    illness  of  six   weeks.     After  an   interval  of   two  or   thiv, 
weeks  they  reeiureil  ii;  the  second  Week  in  Deceniher,  and  con- 
tinued until  Dceeniher  iW.     She  was  well  f„r  a  few  days,  an.l 
then    the   attacks  recurred   alter  slcpin-'  in  a  cold   hed,' an.l 
persiiitrd  iiniil  her  admission  to  hospital  on  February  \i.     Fei 
thi.   four  weeks  previous  to   entrance,  the  attacks  canie  ever\ 
tw.dve    hours    rej,'ularly.     A    mitiniur    was    tiotieiMl;    hut    tl„ 
history  of  aj,nio  was  so  clear,  and  the  attacks  «o  elia'racteristir, 
that  ii  suspicion   of  malignant  endocar.iitis   was  at    first    no' 
•  iitirtidiied.      It  was  only  after  the   failure  of  (piinine,  and  a 
variation  in   the  character  of  the  paroxysms,  that   a  diagnosis 
was   reached.     In    this  case,  the    most    protracted   with   whi,  1 
I     am  'acipiainted,     the    cor.dith.n   persisted    for    more    thai 

''^''    "•''".    i""'    l->''.    IJnstowe   has    informed     me   that    h, 

regarded   tht'  case  as   (Uie   of  ulcerative  endocarditis  from  tli. 
outset. 

1  have  recently  had  under  oh.scrvation  a  remarkable  cas. 
wiiieh  the  symptoms  persisted  for  nearly  ten  months;  ;iii^l 
through  the  kindnes.s  of  Dr.  Mullin  of  Hamilton,  Ontario,' 1  ;,,„ 
able  to  give  the  notes  of  a  second  case  in  which  the  disr,,,, 
continued  for  eleven  months.  The  clinical  features  of  tin  .. 
two  cases  may  thus  bo  summarised  : 

(1)  Daily  intermittent  pyrexia  for  many  months,  the  tenipn,-, 
turo  rising  to  102^'5  and  104°,  occasionally  preceded  by  :, 
distinct  rigor,  more  commonly  by  feelings  of  slight  (•hillill,■^^ 
Following  the  pyrexia  then'  was  more  or  less  sweating. 

(2)  Progressive  failure  of  strengtii,  with  varving  iirtcrvals  ,,i 
improvement. 

(••};  Physical  signs  of  cardiac  disea.se— in  the  cases  h,  r^ 
reported  an  apex  systolic  murnuir,  with  hypertrophv  of  ijir 
left  heart. 

(4)  Developmout  towards  the  close  of  the  embolic  symptnn,. 
more  usually  associated  with  ulcerative  endocarditis,  ,iii,| 
cutaneous  ecchymoses. 

'  Xcilnchrifl f.  /.Nil.  Mill.,  vol.  iv.      licrliii. 
'-'  ./!rili\-/i  Miilii;il  Jiiiirniil,  l.Ssl. 


Ill 


i'i:\  III! 

'       I'llf.     till'    liiu.st 

l>i.  Miistowt'.^     .A 
or  twicu  11  (liiy,  in 

of  two  or  tliri( 
'ceiiilifr,  and  con- 
V  a  tow  (lays,  anJ 

a  cold  l)fd,  uikI 
'(■briiary  12.  For 
at'ks  cainc  aww 
oticcd  ;    lint    III, 

so  cliaraclrristii 
was  at    Hrst    \\u< 
)t'  (|iiiiiitu',  and  ;i 

tiiat  a  diagnosis 
ftod   with   wlucli 

for  iiioru  than 
cd  iin<  that  Im 
■arditis  from  th, 

larkahlu   case  ii, 
II    luoiiths;   an^i 
m,  Ontario,  I  .im 
hich   the  disc.iM 
'futures  of  thi- 
ghs, the  tein)iria 
preceded    In    a 
slijjht  chillinrs.. 
veating. 
ing  intervals  o| 

the    oases   Ik  iv 
ertrophy  of  i|i,. 

ibolic  synij)tiiiii> 
iiliicarditis,   ww,] 


'"'  I'-'^i'ixMihin.- 


Tl 


le  anatomical  cmdit 


••irgo  vegetative  out. 


ion  in  hoti 


,\Ii.ss( 


r.-A.  H. 


■rout  I 


I  ca.si'.s  was  th 


IS  on  the  mitral  val 


io  .same,  n:in 


■'I'-fd  fortv-tlin 


Ve 


■'y 


;"ri  lotlieiaivat,.  ward' of  th,. '., 


March    f.'J,    |,S!);> 


<\Uvn\ 


••oni|.l,iinii 


';;■   of 


""■''••'"lilt,   admitted   I 
"'"'^  Ifoj.kins  Kospit.d 


rom 


''as  an  e.v( 


^viakiie 


on 


'he   onset  of   th 


■"'  '"'"ily  •■""d  persoiuil  I 


ss    ;in( 


lev 


er. 


'i'h 


'•Evenly  ye,i,-.s  ago   |„.    | 


I'l'-^'iil    trouble    I 


winch  he  w.as  e,j 
man  there  is  mi  i 


dined  to  hed  f 


'".  ••'^•■"■I<   of   typhoid    f 


was  "chronic  ma 
■iuy  exci'sses,  e.\e( 


i"'il''fined  history  o| 


aria. 


'"■''•  '•'  no  hist. 


I'inl 


His  pres.nt  illness  l„ 
.'"ccoinpaiiied  by  i\.^^ 
iii'ss;   lieadaohe,   l„.«s   of 
marked  sympt 


I"  I'-'ilnaps  in  t.ibacco. 


"•'^'"'•.v,  and  up  t.. 

';"s    ..njoye.l    good    health. 

''"ver,   with 


young 
IS  or  ot 


"I  SIX  Weeks: 


and  wl 


lell   a 


■'>"  attack  .d  what  | 


"•y  "f  syphil 


"•y"".  •■'uly  i„    I),,,,,ni!„.r   |,S!)| 
'    '•.yL''H'nil  malaise,  an.l 


with 


-•'ppetiti 


;.ive   us   t 


oiiis,  and  also,  accord 
"■«e  details,  marke.l  sull 


MlSomiii; 


and 


iii< 


niiiseiilar  s.jr 

cough     WCK 


"  "'••  I5loek,  who  kindh 


spli'en  was  enlarged.     Tl 


"sion  of  cHint 


•'  '"w  days,  and  he   inipiov, 
lii^^  business.    In  about  thre 


verity  of  the  sv 


eiiailC: 


Th 


lar  its  t 


'"I'tonis  abated 


111 


'h>pnu)a  with   iner 
time  that 


weeks,  | 


'   ilttempf   to   eont 


:i  (la 


ilvf, 


ne  had  a 


■t.'.ising  cough,  and  it 


lowev.T,  thei 


mill' 
'•'  \vas  m;iik,.,| 


h)Ud 


ystolic  murniiir  at  tl 


was  noted  for  (J„.   fi 


iiioinin. 


>-'Ver  ofan  intermittent  type,  usuall 


'L'apex.      11 


e  ha.l 


■'"Id  i-anging  from    K 


y  siib-i 


lornial   in  tl 


"ccasioiial  sweat.- 


ffe 


•5    in  t 


'"•  '"'dy.  particularly  in  the  let 


(•-"iplainedofpainsin.lirt 


le  eveiiiiiL 


le 
with 


t'li'lerne.ss  over  thi.  foin  t 


f  iiigiiinal 


''t'.Uioii,  ain 


till'  steriuin 


iroiii 


Insisted,  and  there  w 


," "'  ••""'   fi»'f''   ''-•ft  e.istal  cartil, 
"»'t   the  winter   the   int 


•-''''■lit  parts  (,f 
'liere  was 
igi's  near 


lie  wa: 


i  confined  to  his  bed  for  tl 


■cie  weakness, cough,  and 


lie   conditi.m 


le  greater  part  of  tl 


crmittent   fever 
'ly-^pmea,  sothat 


iiiider-sized  man  of  f 


•"1  iidmission  was  as  foil 


■TiiJ'inie,  and  with  a  sail 
"'"1    red;    the 

""■'I'"'!'  volume,  the   t 
imt   stifFei 


'"'  iiiiiscula,tun 


le  tinu 
>ws:    I'aticnt 


IS  an 


!ow  CO 


inplex 


not  emaciated;  slinhtJ, 


paj)illa'  ]iromineiit.      Puis 


'""•     The   toiin-, 


led.     The   te 


ension   a 


III 


bout 


se    IS    !)l', 
normal.     Tl 


perature  at  the  time  of 


was  normal.     The  thorax  is  well-forme 
mMisston  gives  everywhere  a  full  and  d 


le  is  clean 
regular,    of 
't!   radials  are 
exanii   ation 


•iif^f^iiltation  ther 


■0  are  heard  normal  b 


c'le  costal  angle  good, 
lear  resonance,  .nnd  on 


leezy  breath-sound 


'/'///■;  cinioxic  i.\Ti:u.MiiTi:.\T  i'i:vi:i; 


ffrrirf.—Tho  impulse  is  f'ocbly  visible  in  sixth  iuieispatv, 
•S  cm.  outside  of  nipple  line.  Tlie  impulse  e.xtends  as  far  as 
the  parasternal  line;  it  is  nut  forcible,  nor  heaving.  Oi, 
I>alpitaHoii  the  shock  of  the  second  sound  is  well  felt  over  th( 
whole  pnecordial  area.  There  is  no  thrill.  The  impulse 
at  the  point  indicated  above  is  visible,  but  scarcely  palpabK 
It  is  mo.st  forcible  in  the  parasternal  line  in  the  fifth  interspace. 
The  area  of  absolute  dulncss  begins  on  the  fourth  rib  in  thr 
parasternal  line;  does  not  extend  beyond  the  nipple  to  the  left 


no 


oyond  the  mid-sternal  line   to  the  right.     Auscidtation 


ir- 


In  the  apex  region  there  is  a  loud  sy.stolic   murmur  of  a  .son., 
what  musical  quality,  -.vhich  is  propagated   to  the  axilla  autl  is 
well  heard  at  the  angle  of  the  scapula.     It  almost  completelv 
masks   the  first  sound.     Towards  the  sternum  it  diminishes  ii: 
intensity,  but  is  well  heard  at  the  ensiform  cartilage,  and  is  feebl\ 
heai'd  as  far  as  the  right  parasternal  line.     Along  tho  left  sternal 
margin  it  tliminishes  in  intensity  above  tho    fourth  rib,  and  is 
only  ju.st  audible   in   the  second    left   interspace.     Thc'secou^l 
sound  is  very  loud  along  the  left  sternal  margin,  particularly 
be.,  w  tho  second  interspace.     The  sounds  at  the  aortic  cartilani 
are  clear,  and  there  is  no  diastolic  murmur.     Both  sounds  ai\ 
audible  in  the  carotids,  the  second   not  accentuated.     There  is 
no   distension   in    the    veins   of    the   neck;   the   aorta   is   n„i 
palpable  in  the  sternal   notch.     There  is  no  tracheal  tugging. 
.Kxamination  of  the  abdominal  urg:>ns  is  negative;  the  edoe  ( I 
the   spleen   cannot   be     felt:    the  dulness    is  almost     ent'irely 
masked  by  colon  and  stomach  tympany.     The  liver  is  not  en'- 
larged  ;  there  is  no  swelling  of  the  lymphatic  glands. 

Urine— Six  gr.  lOlD,  acid,  no  albumen.  The  blood  conn! 
showed  above  four  millions  of  red  corpuscles  to  the  cubic  mm., 
and  marked  leucocytosis,  the  ratio  being  one  white  corpuscle  tu 
seventy-five  red. 

The  patient  was  under  our  observation  from  March  1.-,  U) 
May  10,  and  his  history  during  this  time  may  be  thus  snm- 
marised.  Fever  :  the  temperature  was  taken  every  four  In.nis. 
During  his  stay  he  had  no  chills,  but  he  frequently  had  sii  .l,t 
chilly  feelings.  The  usual  cour.se  of  the  temperature  wa.s^.s 
follows.  The  morning  record  varied  from  D7°-5  to  0«'.  A  iis,' 
took  place  through  tho  morning  huurs  and  usually  about  4  p.ni 


<>!■'  I'.XlXKWh'Diris, 


ig",  .'111(1  is  ffc'bh 


'Ik.  maximum  was  reacUl,  from  10-.   ,,,,,,...,,         , 

'lie  (.■vemiiif  hours  tl„.  f   ,  "  -  "'<-'ii,  tiir,,|,n|„,„t 

--<i-- not  nntU  the  ii  "  ^^^^^ 

'">•  P-fuso  ;  nmre  fre,uontIv  H.  '''"^"""'  ""•^'■^'""- 

'"'•"■»  April  14  to   •>4     h     f  V      ■     ■'",  "'■"  ""'•^'  ■^"^^''^'^^-  '"-^^ 
''•'-Shisstayi.l      ,,f^:,7'-^^^ 

'^0^     Thopulsoran'od  il   si    ,      ,0^"'  ''^^'^   ^^"^  '"'"- 

"-   yonoral   cunditiun    im^n  '',""" '""''■ '"'■'•--''• 

^"Sl'tly  in  weight.    The  H  "7'"''   ""'    ''^^   ^--'' 

-y  special  ga^nctrolj^'H'       T"      'V  ''^^   ""^-'  '-'' 

V7<iisti.,ctte„.,er.e;!:t:;r::r''''''^"'''"'  ^^'---^^ 

"''literatinn.    tl,.   first  '"  '^''^"''^"  """"'i'>-  at  the  ap.x 

'''■term.Me,l  in  tlu.  a,va  ofc.,nli!    f ,  *  '""■"'"'^  ''""''^'  ^^ 

Mortic  region  remained  cleir      Tl  '.'"•     -^'"-'  ^^0"'ih1s  in  tiie 

-  U.  a.  the  1.^^^^ 

';-  of  fl.e  patients  death.     From  tl      i  V'"".  "^'  '"  ^''^' 

tl'^  temjieratnre  range  throu-d.o^    r  ,  J"^'  ''  ^'''^''''''^  ^''■■'t 

""'•^  •     I"  .July  th,  '' ,,  °  ""^  f^'^^'  ^^•"'  •^"■"-'  ^va.s  from  !)7^  to 

^'-  --  ^>l.nost  normal.  Earlv  i  j  ,,  ^^"  V"  ^'"  ^-"1-- 
;--'  .-«ps  of  these  were\  ti'  f^t:  r''^''T"r'''^"*' 
temperature  became  normal  and  rl.     '      /  ^'^^'"'^    ^^    *''^' 

but  the  pulse  was  weal/.id  ,"",  T""'  ^^  ""^'■'  ^'^^  ^^^'' i 
fi'v^t  u-eek  in  September  tl.  '  '"■"'^•^-     ^'"•i".^-  tlie 

-'''"iy-he:,o;:^t:h::::r''?;r^"^"^''^-^^^ 

wns  frequently  0-,°      Thorn,.,        '''    /      '"'"""'""temperature 

"«'  »'i.  u,..ii  L  .icatif '  ,,r;:,r:  r,  """"""''-'•  *-™» 

'■-Sislcrd  9S",  a„,l  ,;„.  ,.  „      ,  ""'  "''»  '""Peralme  o„ly  „„o„ 


8 


Tiir.  ciiuoMc  isTi:i{.\iiTri:\T  f/:v/:/{ 


Tliei(!  \vci-(j  iio  brain  syiuptoias, unci  ho  remained  conscious  until 
tlie  last. 

Antoptiti  (by  Dr.  Block)  made  on  Hcpteinber  1(J  at  9. 1.")  a.m.. 
twenty-one  hours  after  death. 

Body    e.xtrenitily    emaciated;    abdomen    strongly    retracted 
ligor  mortis  very  sliglit;  petechia}  universally  distributed  ovci 
the  skin  and  mucous  membranes;  cornea.'  clouded  and   pupii.- 
eipiidly  dilated;  depmident  jiortions  of  body  cedematous. 

Tliiii'iir. — Left  pleural  cavity  contains  about  four  ounces  i,\ 
serous  tiiiid  ;  no  adhesions.  The  right  pleural  cavity  presented 
adhesions  in  the  upper  lobe,  of  old  date.  Posteriorly  hypostatic 
congestion  of  the  lel't  lung;  right  lung  he;dthy  throughoiii  : 
[)etechial  spots  well  marked  on  both  pulmonary  pleura". 

Ucttvt. — Pericardial  sac  contains  a  small  amount  of  fluid,  no 
evidences  of  pericarditis  ;  heart  firmly  contracteil  ;  left  auriiiilu- 
vontricular  orifice  easily  admits  one  finger;  the  valves,  chidlv 
on  ventricular  surface,  e.sjjccially  of  the  posterior  leaflet,  beiiiM 
studded  with  an  enormous  mass  of  vegetations,  some  of  which 
had  undergone  calcareous  degeneration;  the  chonhe  tendinc;c 
thickened,  and  studded  with  similar  projections;  right  auricido- 
ventricular  orifice  easily  admits  two  fingers;  valves  normal, 
jjulmonary  and  aortic  orifices  and  valve  normal,  and  the  vessels 
free  of  clot,  seemingly  healthy.  A  few  petechina  on  the  sereus 
coverings  of  the  great  vessels,  lieart  muscle  pale  and  linn. 
The  heart  ui  tolo,  though  apparently  small,  corresponds  with 
the  weight  of  the  body. 

Ahdominal  mviUj. — Spleen  slightly  enlarged  and  of  al).iut 
normal  consistence  ;  at  its  inferior  extremity  an  abscess  ceii- 
taining  about  three  ounces  of  dirty  sanious  pus,  with  thickeiici! 
wall ;  a  large  anaamic  infarct  just  above  it. 

Liver. — In  size  corresponds  to  the  body.  Gall  bladder  full;  iin 
evider.^es  of  disease. 

/v/(///n/.i  — Relatively  increased  in  size,  pale,  capsule  easilv 
detached  ;  there  is  an  amenuc  infarct  in  the  medullary  struc- 
ture near  the  inferior  portion  of  the  left  organ. 

The  iKi-iloiuum  generally  studded  with  petechial  c.\tra\a.si- 
tions. 

S/.oii>i(r/i. — Kmpty,  small,  coated  with  mucus,  walls  thrown 
into  longitudinal  folds  .and  somewhat  thickened  ;  mucosa  of  an 


'.  I 


OF  E.\D0CARDIT/S. 


9 


r  10  at  9.1. Ml. II 


bladder  full;  ii.. 


cliial  extravasi- 


i"ton.se  pinkish   hue,  .„,!    uniformly  tin,.o.]    wi*I 

>ub-nuicous  extravasations.  °  ^''    '""^^"•'^  '^'"1 

J'<frs^i.c~J,junniu,  ileum,  and  colon  marked  hv  1  ,      • 

-  Ntrava.sat>ons,  not  so  intense   howeve.  ,    '  ^^^^n^onh^u,, 

..i-s;  the  mesenteric  , land;  I;:       rrdnr^^^^^^ 
very  much  reduced  in  volume.  '  '"t^'stuies 

^ram  not   examined.     N      hir^fn,.;  i     ■     . 
^■"Itures  made.  bactenolog,,r,l   examir,ations  or 

,,^f''    "•  (R^'Po't    hy  Dr.  Mullin).-Miss  F    r  ,    , 

'•■'"'er   dieil   of  aneurvsm  nf  tl       r    .  ''  *'^^^'^'    -^■ 

'1'^'   aorta,   at   fiftyl,;  "l. ''"■■  '"*   '"'''^    "*'  ^^e    arch    of 

-''.except  that  sL  has  IXerwl^riJrtt"     '^"^^""' 
'"■ens.ons.       Three   brothers  and    o  ^'  "'  ""  ''"''^'^ 

;:-ti-j..s  disease  of  ti:3^;l^,r:,r^^ 

1 1"-' patient  has   oenerallv  onin,     i  ,    '"^''  "-"rgitatmn. 

y--  of  age  she  In  1  In   -ftt  cf       T"'  '"''''  '"'  ''^  *-"'- 
^'■vere,  as^he  was  mil' "^\r    >l'eun.at,sm,  apparently  not 

='""f  the  tin.e      Abo   .  "  ^"""   ''''^'' '"'^   ""^  in   bed 

^''■--''^'-'paintd^gr::^^^^^^ 

-.<ined  to  bed,  but  wore  a  ^lint  W  a  IJ^  ""si  T'  "T  ""^ 
b-n  pale,  and  .heu  at  boardin..  c Cl  hei  t'  T  ^'"'^^^ 
■^.'^■S-ested  that  iron  would  be  of  use°    SI  ^'''   ''^'^''''   -^en 

■"■  a'"i  scarcely  ever  tlru-du    h  t    .  '       "'"'''  ^''^  ""^  ^^^«' 

-ncnt.   At  time,  howev  ,  ''^^""'"^^  '"^'"^'^'  trcat- 

-^bhing  pain  1;'  Z        i:^  TV"?"  ^^^^'^^  ^''^  ^'^  ^ 
l-g.     The  n^enses  wer^al    av    ,  T'"''''  "^^'^'^  ^^^^t*-^'' 

i.^.  aud  had  pain  in  ^  i^'^:,  ^i'^  "f  1T  ^°'"-^"- 
'■^=a""-e  t"  go   to  bed      In    M...  i      ,  ''"'*'  ^"'  '''''   '"^t 

X.^.ara  ..3,s,  where  sl'^emLlttiir 

■"'feed  that  she   looked  miserable  T.  ^"  ^^'-^''^^ ''^''-^"^''^^l^ 

•1^"I<e  of  being    ill      The    , !  *        >""'  '""'   ^''^•"'•^  '^'' 

''.oughtthis.4ther^  n:;:j^::^^7r'^ 

--1.     She  sometimes  had  a    act  o  .     "''  "^  "^"  '''^ 

l^'^-«'  -^'--^y  ou  taking  a  sti  u^  n  si  T  '  "^''^'  ^°"' 
'-•1  'ever  followed  b^  n  d"  sw Ls  ^I  ?""  "'^^'^"•'  ^-' 
^1'*' ^'fternoon.  A  physician  ■.;  ''  ^'''''  ^^^'"«  '^'^  i" 
--  aftbcted   and     1        s  '""'T   '"'' "'"   •^''^'''   ^'"^  '--t 

n,   and    rest      S  •      V'^  ^''^''^''^e^   medic.l  t.eat- 

•     "'"^  •■"■'^""'^"'-  »'— r.   to   go   about,    ad 


10 


77//;  cunoxir  intermittent  fever 


n 


' 


frequently  took  long  walks,  though  on  exertion  she  complained 
of  beii;;r  sliort  o1  breath.  She  had  fever  and  sweating  at  night, 
and  was  often  so  restless  that  she  was  obliged  to  leave  her  bed 
and  recline  on  the  sofa. 

Before  she  came  home  her  hair  became  very  thin,  and  mucli 
of  it  fell  out.  It  was  cut  short,  and  afterwards  the  colour  was 
not  so  dark.  Menses  were  absent  only  one  montli,  until  March 
1887,  when  they  ceased  and  did  not  return. 

In  the  first  week  of  July  she  came  home,  and  was  placed 
under  my  care.  In  the  forenoon  the  temperature  appeared 
normal,  but  every  afternoon  it  rose  to  102°  or  103°.  For  a 
time  she  was  thouglit  to  have  typhoid  fever,  but  no  distinctive 
symptoms  appeared.  A  milk  diet  was  given,  but  when  it  bo 
eamc  apparent  that  the  fever  was  not  typhoid,  she  took  such 
forms  of  nutritious  food  as  suited  her  taste. 

The  fever,  especially  from  September,   was  attended   with 
sweating,  more  or  less  profuse.     It  was  often  noticed  that  when 
sleeping  in  the   iifternoon  her  hair  would    become  wet    with 
perspiration.    No  local  symptoms  arose  to  account  for  the  fevtr: 
pain  was  not   complained  of  to  any  great  extent;  sometimes, 
for  a  few  hours  or  half  a  day,  there  would  be  aching  and  pain  in 
the  hands  and  different  joints,  but  these  were  always  transient 
and  at  no  time  after  she  came  home  was  there  marked  tender- 
ness (ir  swelling  in  any  of  the  joints.     When  she  reached  honie 
there  was  some  swelling  of  the  ankles  and  knees,  but  this  souii 
passed  away  as  she  remained  in  bed.    Not  making  any  exertion 
she  (lid  not  suffer  from   dyspnoea.     There   was  a  loud  systolic 
murmur  at  the  apex  ;  and   from   the  first   the  signs  of  liyper- 
trophy  showed  that  mitral  disease  had  existed  for  some  time. 
Before  she  came  home  it  was  noticed  at  the  outset  of  the  ill- 
ness that  small  spots  appeared  on  the  hands  and  feet,  also  on 
arms  and  legs  and  face,  that  looked  like  "  hives."     These  con- 
tiiuied  to  appear ;  they  were  erythematous,  some  as  small  as  a 
pea,  others  as  large  as  a  five-cent  piece,  with  a  white  point  in 
the  centre.     They  often  passed  away  in  a  few  hours,  and  never 
lasted  longer  than  the  evening  of  the  day  on   which  they  ap- 
peared.     They  were   not  numerous ;    .sometimes    they   would 
appear  near  the  tips  of  the  fingers,  which  for  a  short  time  bc- 
oame  swollen.     These  spots  wei-e  .seen  nmi'!'  or  less  throut^lioiit 


11  she  coiii[)lainc(l 
jwoating  at  night, 
to  leave  her  bcil 

^  thin,  and  much 
Is  the  colour  was 
inth,  until  March 

,  and  was  placed 
erature  appeanil 
or  103°.  Fur  a 
ut  no  distinctive 
but  when  it  Ihj- 
id,  she  took  sucli 

s  attended   with 
oticed  that  when 
Dconie  wet   with 
unt  for  the  fever: 
tent ;  sometimes, 
;hing  and  pain  in 
always  transient 
marked  ten(h'i- 
le  reached  lioine 
3S,  but  this  soiin 
:ing  any  exertion 
a  loud  systoHc 
signs   of  hypei- 
for  some  tiino. 
Litset  of  the  ill- 
nd  feet,  also  en 
vs."     These  con- 
le  as  small  a.s  a 
I  white  point  in 
liours,  and  never 
which  they  ap- 
les   they    would 
L  short  time  be- 
legs  througiiout 


OF  FXDOCAI{-)ITf> 


the  illness,  th(.iio| 


.Sli 


ic  ha<l  fre,,uently,  at  tl 


'  "i'"e  of  them  W( 


I'e  nuticed  in  the  earl 


marked,  sen.sations  of  d 


l"^' time  „f  the  day  when/ 


II 

y  j)art 


It  distant  intervals  tl 

lior  sister  said  that  "the  bed  fidrl 


iillinoss,  and  .several  t 


I  ere  w.Ts 


"f '  '■^'^■''■'•.  '•^'"l   very  pr„f„ 


a  sever 


vsl 


e   riiror 


ii/ok. 


Tl 


v-iiiable,  never  ve 

t"  take  fu„d.      The" bowel 


se  sweating.     Tl 


ever  was  \nu\\- 
lines  ill  the  wiuter 
on  one  occasion 
lese  were  fi.lj,, wed 


ry  good,  and  often  it  was  difficult 


le  a  p  pet  it 


•  '  wa.s 


nil 


iiU'iiie. 


line   was  examined   fi 
«.tsadepo,sit,of„,ates,butthro,i.d.Vh 


'■'  ^-^qi'ircHl  the   u.so  of  mild 


to  tempt  her 


J'lirgative 


■ecpiently;  .sometimes "tl 


!iere 


Hess  the 


tl 


urine  was  n 


lere  was  then  anl 


oinial;   i!e/(r  tl 


le  end 


<-'  greater  part  of  t 


!<•    il 


»iis  a  sliyht 


'^■'Ha  of  the  ftce  und  extr 


illtumen   was  f,,uii 


iiess. 


ght  cough  Lite  in   the  ill 

"■ynidications  of  lung  disease.     Tl 
.Vboiit  two  weeks  before  deatl 


At 


'emities.     Tl 


lere 


"0  time   w 


'^:\\t 


tl 


le  sti 


iiere 


attack    of  djarrl 


without 


'ffia   occurred,    lastin-^    f 


•eim-th  failed  gra.luall, 
'I'l»areiit  cause,  a  .seven 


l"^vMg  morning,  after  which  the  d 


rom  4   p.m.   until  tli 


'•apid      About  three  days  b..forede.atl 


L'cline  of  strenoti 


liad  been  cl 
A  careful  t 


the 


I  w,is  more 


t^r  and  active,  became  clouded,  and 


iiiind,  whi 


uniperaturo  record  was  k 


eh    Ik; fore 
shedi.Ml  in  conn 


1",  1SN8,  until  July  7,  ]8,s!).     rpi 
">onth  remarkably  uniform  ■  tl 


Tt  in  this  case  fiom  July 


f  tyjie  of  fe 


below  the  normal 


'e  morning  record  al 


ver  Was  in  each 


io;r 


and 


pointy,  and  the  evening  record  ,oacl 
intervals  f,.r  a  week 


•sometimes  104'.     At 


ovenmg  temperature  ,lid  not  fall  bel 
The  anto,,sfj  showed   moderate  eid 


\\'ays  at  or 
!iing  102''-;j, 
or  two  the 


chieHy  to  hyperti(,,,hy  and 


aortic  valves  W( 


Pl'y  and  .lilatation  efthelel 


low  ]00'. 
trgement  of  the  heart,  d 


ue 


tu-o  fin 


"•e  normal  ;  tl 


;crs ;  the  valv 


t  ventricle 
<-'  niitral  orifice  readilv  ad 


iiuinerous  I 


"  s_^y'Hents  were  thickened  and' 


Th 

mitte( 


■"■go   vegetations,  chiefly  on   tl 


ami  exteiuling  fn),„  the  base  of  tl 


I'leseiited 
auricular  surfaces 


the   left   auricle,       Tl 
"11(1  thickened,  and 


MiDrtened 


ve.i^vtatioiis.     Tl 


lie   chorejt 


iG  posterior  .segment  to  t|, 


teiidin 


le   SI) 


many  of  :he 


'a'    were  a  little 


farets  in  all  ,st 


•gi's  of  chan 


T'^'L'n  and  kidneys  cont 


111  eiicru.-^ted  with  th 


ained  iiumerou.s  i, 


'- •''■"-■'>■ -'"■-^-:"::'''^:;r-:;:-:' 


*"■ 


12  /.\T/:/i'M/TT/:.\T  I'LV /■:/,•  of  EX/)OCA/n)/TlS. 

;is  in  Dr.  ^Iiillin's  cnsr,  tin-  disoiise  is  lit  first  tlioii,i;lit  to  bu 
ty)ili()iil  fever.  In  (Ji(sr.  I,  prior  tu  the  onset  of  iiis  illness,  the 
patient  Wiis  not  known  to  be  the  snhject  of  valvnhir  (ii.seiise 
wliiie  in  Case  II  it  is  very  probable  that  tiie  attack  of  rlien- 
niati.sin  at  the  twelfth  year  laid  the  foundation  for  clironii 
mitral  lesions. 

In  chronic  valvular  lesions,  particularly  of  tlie  aortic  segments 
there  may  be  persistent  fever,  rarely  however  (jf  a  typically  intei- 
mittent  type,  and  in  a  majority  of  instances  the  cardiac 
features  of  the  case  predominate.  The  special  interest  of  thr 
^roup  illustrated  by  these  cases  is  the  chronic  intermittent  fevn 
with  progressive  failure  of  health  and  strength,  without  dyspn(ea, 
ana.sarca,  or  other  features  of  valvular  disease. 


RICHARD  CLAV    AND    SONS,    LIMITKP,    LONDON    AND   lllNOAY. 


Cx 


X  /  ^ 


J^^i>rUac^rom  the  Journal  op  .Vervo,-.,  Avn  « 

■ ^^^°ll^!^^ff^^TAL_D..SEASE,  February.  ,<,,,. 


''•V  WIIJJAM    OSLICR,  M.D. 

-■.s  l,,.vo  p.»s«.  si,K.e  Huntingdon,  in  „  r,..t.lZ^Z 

'7'-  ■•'"'•,  "'-"fo"--  had  observed  in  L„ng  I  H,^ 

..  the  whole  „n«e  ,.f  de.seriptive  „„s„,„„j.  there  i7„' 

..  my  tao..,edge,  ...„  instance  in  which"     .Z^^^ 

been  so  accnratoly  and  f„„y  delineated  in  .so  fc„  „  ^ 

^o  d  tatis  were  given ;  the  original  cases  were  not  ^ 

(noM.av^ttey^ee_nMesc.*ed  .  bnt  to  H„„ti„gdo„" 

original  ftn.il,  y,,,icl  the  it      fr   V  "'f'>""»«°"  "l»i«  «.« 

«..ed  „„..,  „ji„„  .ot^l™:s:;;:,r  ;::'•'■,"  "r:  "'•"""- 

could  not  I)e  seen.  I'^tncss  o.,  the  subject,  the  patients 


i. 
I 


.( 


2  ii//./.f.i.M  osf.r.h'. 

account    of  tlu'    symptoinaUiloyy  no   essential    fact    has 
l)ccn  added.     Within  the  past  ei^^ht  years  a  copious  liter- 
ature lias  ^-athcrcd  around   the  subject  ( particularlv  in 
this  country),  which   is  available  to   1.S.S9  in    the  niono- 
}4ra])h  of  lluet.'     Since  this  date  the   interest  has  even 
increased,  and   the  references   stand   thick  and   close   in 
the  Index  Mcdieus  ^or  the  past  three  years.     The  recent 
paper  by  Sinkler  ( JAv/Zo?/ A'fvwv/,  March  u,  i.S(;2)  j^ives 
the  literature  to  date.     The  ])ractical  outcome  is  that  we 
now  know  the  clinical  aspects  of  this   form   thorou(,dilv, 
and  I  have  nothinj^-  unu.sual   to  ol'fer  in  the    history  of 
two  Maryland  families  which  I  have  to  report;  but  the 
connection  of  the  chronic  choreas  with  each  other  and 
their  relation   to  chc -ea  minor  are  questions  which  niav 
be  discussed,  and   upon  which   we  need   fuller  informa- 
tion. 

A  chronic  chorea  of  adults  and  a<4-ed  was  reco«-ni/.ed 
Ion-;-  before  1  luntint^clon's  description  of  an  hereditary 
forni  in  adults,  which  was  it.self  antedated  in  this  country 
by  the  observations  of  Waters,  (iorman,  and  J.von. 

Provisionally,  at  least,  we  may  place  the  eases  of 
chronic  chorea  in  t"our  ,L;-roups: 

I'irst  t;-roup,  chorea  of   infants,  appearing  either  at 
birth  or  within  the  first  two  (jr  three  years  of  life.    Until 
recently  but  little  attention  has  been  paid  to  these  inter- 
estinj;-  eases,   of    wliich    there    have    been    several    well- 
uiarked    examples    at    the    Philadelphia   Infirmary   for 
Nervous   ]  )iseases ;    one    has    been    reported  by  vSinkler 
and  two  by  myself,     A  rrsin/n'  ni  the  literature  to  date  is 
i^iven  by  Audry  in  his  recent  monograph  upon  "  Double 
Athetosis."     The  cases  heretofore  described  may  be,  as 
he  says,  divided  into  those  in  which  no  accurate  account 
is  given   as  to  the  existence  of  spasm  with  the  move- 
ments, and  those  with  explicit  statements  as  to  its  pres- 
ence or  absence,    A  majority  of  these  eases  are  examples 
really  of  spastic  diplegia,  plus  movements  which  may  be 
choreiform,  iremulous,  or  athetoid;  or  there  may  even 


'  De  la  cliorec  cliioiiiiiiic,  Paris,  18S9. 


r.'/™-/7/.;.v,v-rw,v,v/,-, ■//„„■/..,  , 

"l..sc.nxT  can     ,  ",,',;«':■  "  'r  -;"""-ly  .lilliad..  „„, 

ing-  case   illustritrs  ,.li,>,-,>,v       '''^" '^""'^^  •      i  he  I., How. 

J'cmale,  aged  four  and  n  h■^}r  ,. 

^■.U-Inh  month.  Xothino  .,  ;  I  V  '"'"^'^  ^'"'f'*'-^'-  ^^'^o  at 
'^^^'\v  at  l>irtli.  it\?4  "t/'Z  ^'^'''^^"''''^^^'^^  ^^'^o^'t  the 
^^•^>11-  Xo  alMi(,rm aii  V  Jn  '/  •^"l>«^"qiientlv  throve 
child  beo-an  to  c    vn  '    - ^  ^'"til    the    other 

;^nd  could  not  hold  .!n  to  a   ,.      n.:'"\r'^"'"^'^^  '^^-''<-ard 
ar  movements  were  noti,  tV  ,    ^i'  ""''  >'^^'^"'  in-emi- 

have  continued.  Tect  wel  nt  *;  n™''  ''"^-'Uej.s,  ami 
and  she  beo-an  to  [a]  at  the  n  V'"  ^'""''^^^  month, 
walked.  The  ciiikl  s  bi-tl  ,•  \''',r^  y^"''' '  '^'^'^  "eve; 
;vcll-forn.ed  head  does  ^^' dd  I  i^^^'^^^^""'-^^'  -'^h 
taRmus;  talks  a  Lnbberisl  of  1  V  t  ''""^^  ^'^  ""  "V'^- 
word  or  two  but  wh  VI    ft  ^V""^'  ^  '"'i"  «^"lv  catch'  a 

-ell.   Movent    j^l^    S^^'^^^'  "^^-stands  ^iite 
^I'stinet  o-rimaces;  mov^LiK  of  t     ""'-'' "'^^'^'^'^^^le;  "" 
arms  are  in  e()ns  an    \^wV        i    ^""^'"^^  natural.     The 
n|le,  but  oceasic^:^;^  ^^^^  f^^^^^  i-egular  as" 
Ihe  fingers  do  not  d  snl-iv  nH,  ;     f        ^^^^'^'^l'  objects, 
cannot  use  a  spoon  but  rnn^f  athetoid  mox-ements.     She 
The  mother  if  u^e     1  -t     /e"'^  '''''"^'"  ''''^'  ^^'-^^^^d.  e  c- 
-ts  up  well,  but'tl^'hiL"^cSaiK-""""^^^f   ^''- 
with  a  jerk.     The  feet  are  ev?;,  i    i  '   '""'"^^''^  forward 
varu.s  position,  and  the  tois  St,'  f'^'^  ^'^'^'^^^P^'^  ^quinc,- 
toid  movements.   The  k-  s  nr?f,        ^^^'^'^^-^'""^^Hy  in  athe- 
ently  stiif ;  the  muse  eslriar  but  ./  ^"^^'^'ible,  not  appar- 
In  taking  off  the  stcK^-nol'  i        "^ '''''■>' '''^'"  ^evelcmcd 
and  were^  hard  to     Sid  "?  the  I?"'"'  '^'.  ^"'^^  ^^iff  Jn  Ji" 
became  strongl;-  flexed  "'''"•  ''"'^  ^^^^  ^^'ff  toes 


■ 


4  WILLIAM  osi.r.k. 

This  case.  bfl()nf,''injr  to  Ww  j^n-ciup  (k-scribcd  in  litera- 
ture as  clioiva  spastica,  is  more  properly  a  spastic  para- 
plej^na  with  chorcifonn  and  athctoid  movements.  The 
following-  is  an  illustration  of  a  less  common  type,  in 
which  there  was  no  sp.-ism  and  the  movements  were  of  a 
more  characteristic  kind. 


^.  (r..  aj^ed  ei,t,dit  and  a  half  vears,  the  eldest  of  two 
children.      The    mother   had   twitchinj;-   of    the   evelids 
when  younjr,  but  there  are  no  nervous  troubles  oY  anv 
moment  in  either  her  own  or  in  her  husband's  families. 
The  p.ttient  was  a  delicate  inf;int.  but  throve  fairlv  well" 
learned  to  walk  and   to  talk  at  the  iisual  time.     About 
the  fourth  year  it  was  noticed  that  she    had    irregular 
jerkinj^-   movements   in   the    arms,    which    were    ni7.ved 
about  wildly  and  even  thrown  over  the  head.     She  be- 
came excitable  and  irritable,  and  slept  l)adly.     Within  a 
few  months   the    face   became   affected,  and   she    made 
(grimaces,  and  sometimes  a  peculiar  {^-runtin^-  noise.    The 
leys  were   involved  shortly  after  the  face,  and  at  times 
she  walked  with   difficulty.     When  seen  in    iSoc  more 
than  four  years  after  the  onset,  she  seemed  a  well-'orown 
child  for  her  aj^e,  was  not  ana'inic,  a  little  nervous  m  her 
manner  and  excitable,  but    intelli<,a-nt   lookin<>-.     After 
sittini;-  quietly  for  a  few  moments,  the  arms  jerked  about 
and  the  lace  twitched.     The  right  arm  is  inost  affected, 
and  is  twisted  about  in  an  odd  wav,  and  lifted  as  \\vyy,  as 
the  shoulder.     The   Icf^^s   are  now  not  much,  if   a^t  all 
attccted,  though  she  iitlgets  about  in  her  chair.     When 
watched,  the  movements  are  much  increased.    She  feed,s 
herself  with  great  difliculty.     There  is  no  spasm  in  the 
muscles,  which  arc  well  nourished ;  the  rellexes  are  not 
increased.     There  is  no  heart  affection.     Treatment  has 
not  been  of  the  slightest  benefit.     She  is  very  wayward ; 
and  though  bright  mentally,  it  is  difficult  to  get  her  to 
attend  to  her  studies.     There  have  been    no  explosive 
utterances,  or  any  of  the  mental  features  of  convulsive 
tic. 

And  lastly,  some  of  the  cases  of  chronic  progressive 
chorea  with  dementia  have  begun  in  early  childhood. 

Second  group,  comprising  cases  of  chronic  chorea 
without  any  hereditary  anlagc,  in  which  the  disease  may 
set  in  in  childhood,  adolescence,  maturity,  or  old  age. 
JMany  of  the  eases  in  Huet's  monograph  had  no  history 


I 


(.f 

feat 


'    Ih'//:///: 


v  or  r//A 


"-'loiva    in    tlu 

11  rc- 


"V/r   (//,)/,•/.;, 


'•^I'L'Mdani.s.     J 


asc.s  t( 


"    M-'ai-CL'lv 


am- 


f'"-'  'liseasc  has  I 
^'''•-^KTadually  Icl 


•"Uiiin-,!,,,, 


"-•  'listinn-iiislici   f 


^-""    '■"    rhil.II,,,,,,, 


"It  in  inanv  inst 


>r   tile 
'■"111    the 


tia.     \ 


ery  mail 


'■(-••-viuly  iunn 


y  cas 


"1  'I  van'ahle  j 


or  addl 


:inces 


L'srcrirf 


<>nl 


^I'^vltiin 


^■■^  "'■  this  kiini  1 


KTK.d  .,f  tiniL-.   t.)d 


and 


lave  b(jc 


classed  1 
t-'iy  IS  not  ti 


y  .some  of  til 


emeu. 
"   I'eportc'd 


lie  IV, 


e  case 


s  o 


in  J I 


•'^"I'^'e  nian\- 
'leoiiim 


'■""  an  aeut 


loi'ea  in  the 


/) 


en-iiii-hai 


:".^-  ""l^'-I  indeed  in  el 


••-'  '-■"urse,  and 


'•'Med  ean   he 


reeov 


''»'"   I  iNSSi 


»  «  eritieal   rev 


o^'L'asionally  u-jn,    ,i 


le    acute 


lew  u^ 
eoiir 


'""  chron 


i-'ven  instance; 


■ie. 


le  eliorea, 


iiianv  of  tl 

'J'h 
it\-,  the 
tl 


i^'iiinatism,  rend 


ird 


le  occurren 


'^■^L-  are  reallv  inst 
(■'•^'up,  ineltidinu-  th 
•^"-^•alled  Uuntin.'-d 


inees  of  e 
e  case,' 


i"d    the    a.- 

^''"  it    prohahle  th 


in 


soeiation 


It 


""I'ea  minor. 


distur 
V 

pursue 
\ears.  .- 


<-'^'  in  I'amilv 


M'don  s  chore 


nances,  and  a  jm 


«'""ii])s,  a  late 


"•ith  marked  here<I- 
'•  <-'Jiaraeteri/;ed  1 


n- 


>iirth 


n-'>np,eompnsin 


■"«-i-essive  and  fatal 


onset,  psyeliieal 


a  ehronie 


md   ultimatel 


eoiir.se,  and 


ea.sesof  el 


eotirse. 
•"'I'ea  miiK 


"■'"11   the  other  f 


y  recover,     'i'l 


persist  for  montl 


alvseneeof  a 
'"■^arre    m,.vement 


orms  wc  have  I 


ley  differ   e.s.sent 


"■  which 
IS  or  even 


Pi-ogressive  eharaete 


»ecn  eon.sideri 


Pi'\vei-s. 


T 


iie    f 


and    the    ret 


r.  th 


e  more  act iv 


ially 
"M",  in  the 


elironic  form  of  el 


olloWIIl!"-     is 


entjon    of    j] 


e,  quick 


a  < 


!loi 


■ea  minor 


K""d    ilhistrati 


'le   mental 


Alf 


tnfir 


•"i>:<'  O.,  ane<I   t 


niary  of  Xej 


wenty-onc.   ],al, 


-die  n.n-ementV;;;  th 


trunk.     The   aff 


(HIS  I)i,sea,ses.  'f 


er. 


nne  i,  i,s,s 


on    of   the 


'PPlied   to  the 


e  muscles- of  the  f, 


5.  with 


sinc( 
the  f 


wtion    had   last 


ace,  a 


spas- 


I'nis,  and 
.•'rinission 


of  h 


■^  August,  1NS4      TW      '''^^''  ^^-'^'''"'t  inte 


eart  disease      }r,. 
voung-  man.     'j^'h 


IS  a  strono] 


.^'y  I'uilt,  well- 


jerking-  the    head 


npward  and  rot 


■'"iti-act  suddeni 


ma 


th 


Kes  a 


"^inu-  it  .sH,rhtl 


'■<'\vn  int 


jrnmaee,  and    tl 


At  th 


\\-ith  a  wJiistlin 


5P"ek  action,  and  th 


le   mu.scles  of   th 


e  same  time  h( 


th 


Th 
ree  years,  duri 


.^otmd.     The  heart 


c  air  is  dr, 


e   th 


patient  was  under  obse  n-^l    '"  """^  'evolved 
^ars,  durino-  ^k;  ^i       '-^'.\'^"'"i  and  treatme 


"i"ax   are 
wii  in  often 


^^'Iiieh  time  the  eh 


orea 


itment  for 
persisted  with 


WH.IJAM  osi  i:h\ 


llu 


of    the    iniiVL'tnents. 


ft.ilj4li!  >> nations  in  llic  inlensii  ui  mc 
When  I  list  saw  liim  the  twitchiu-  and  jerkin^;- of  tlu' 
muscles  of  tlio  ncek  and  chest  were  present,  bill  the 
facia!  snasni  liad  lessened.  There  were  no  mental  syiiip 
loms,  aiid  l"<>r  the  greater  portion  of  the  period  he  was 
able  to  work. 

()tlKr  inst;inccs  of  chronic  chorea  minor  in  llu  records 
of  the  Infirmary  are  ^iven  in  my  "  Lectures  on  Ch6rea," ' 
two  of  which  are  very  interestinj^-  from  the  persistence 
of  the  svmploms  for  more  than  three  years  with  ultimate 
recovery. 

Habit  spasm,  bej^innin-'  in  thildhood,  m;iy  persi.st  for 
years,  and  is  often  confounded  with  chorea  minor;  there 
are  also  a},^t4ravated  forms  of  convulsive  tic  with  move- 
ments tvpically  choreic,  but  which  can  usually  be  sepa- 
rated from  chorc.i  minor  by  the  existence  of  fixed  ideas, 
coprolalia,  etc. 

The  following-  is  a  record  of  two  family  j^roups  of  the 
hereditary  form  of  chronic  chorea.  The  cases  present 
the  usual  peculiarities  described  by  Iluntinj^don.  For 
the  opportunilv  of  seeing;'  the  members  of  the  lirst  fam- 
ily and  for  the  details  of  the   pedi-rce,  I  ;im  indebted  to 

Dr.  Ellis: 

lAMiiA   \.     iiKsi  (;i;ni:kai  ION. 

A   B.,  an  ICnj^lishman,  married  C.  J).,  a  native  of 

Coimtv,  State  of ,  and  had  of  issue  eleven  children. 

A.  K.  (lied  .a<;-ed  ei.t;htv-seven,  and  his  wife  a^-cd  eighty- 
five.  Neither  of  them,  so  far  as  is  known,  displayed  anv 
mental  or  bodily  peculiarities.  Two  of  the  eleven  eli:l- 
dren  died  choreic  and  demented. 

Of  the  other  children,  two  of  the  j^irls  married  N.'s. 
One  died  a.-^ed  seventv-hve,  leaving-  children,  all  of  whom 
are  in  <rood  health  ;  the  other,  Mrs.  N.,  still  lives,  a<;-ed 
,seveii.tv-scvcn,  and  has  healthy  children:  C.eorge,  died 
a<4-ed  ''Venty,  a  bachelor;  Sarah,  died  aged  fifty,  of 
typhoi..  'o/(  r,  without  issue  ;  William,  died  aged  seventy- 
six,  kav:  •  ..  ;ar}.'>j  family,  none  of  whom  have  shown 
any  .syniT.  ':s  ^!"  ine  disea.se ;  Mary,  died  of  an  acute 
illness,  a'.r...--   f.iLv-five,  leaving  healthy  i.ssue ;   Jane,  died 


Jlcdical  Nev.-s,  Philailcliihia,  Octol)er,  18.S7 


I'.iu//  ■r//;.s  ( 


'/■•  ('//A'i>.\/(     f  •//,./,/./. 


^;aivi.  uuKiiLti  uvfc'  janies  and  Mar- 


'""'"'^'  Ic-atinvs/l  recall  w     ,  u-,!  , .  l'"';'   ^'""t'"-"'"is  an.I 
y^^ars.     J  lis  wife.  ,li.,l  in  d      .H^^        '"'""'^  ^"■^^■'-  ''"'•^v 


•l^v^;I-I)bc;A.rcsheNvas-fnm-; 


•r 


"lUii  a  few  davs  bef„rc  her  i,..,,!  ',"•  ,"'"^'''  ^"  «"  ah.-u 
sixty.fiftl^  vear.  Kx  c^J  Vs I,  1  •''''''"^  "^•^'^"•'•e.l  in  l,e 
she  was  „o-L  entire  vj  ,,',:'";  \/''"^-  ''^'f'-'-c  her  deall, 
^'"-^  very  stn.nn,y-,„^Kd;/;, :::;:•;::  ^'^^  "^-^^^^1  ^ymp 


-Mar^^aret    M. 


>IV«'M.    (.KXKKATIox. 


^'"<l  tl"-ee  are  in  vario,,.  ll!;.:!^:!^'^ 'I'^I-t   the  disease, 

'   nave  seen  two 


">en.bers   oHhe  "^^Imilv  ""^'^^  "''■     ^   '^^ve  seeni;;; 
iii"rteni  on  a  third:         •'  '■^'    Performed    a   post- 

tcr..t  i^s  ln,l  eharitvto  a;;;;' he  thl  '!'"  "I  '""^^  "''^''•^^^- 
l>retod,sturl)cd  mentality  TI,>''"7^'"'V'ties  of  his 
'-;"e  only  by  his  lirst  Wife  <  "''"',"'  .^^^lee.  but  had 
infancy,  but  one  suryiyin  .  Vn  ''"''  children  died  m 
patient  I  eould  not  sec'  ^  ""  '"  •^'"•"'^  ''^"alth."     This 

[''••t£tr^e;;^;^^.^S\SS;!d^^     ^'-••-  ^-^  >-'■ 

iK-r  mV^.Vhth  year  She  w?s  "r  ^^'^■^•'"'^^''^  '.^wo.  in 
"early  a  j-ear  befo^-  her  dl;  li  7wf  '"  '^'-•^-  ^'^'^  ^-^ 
IVnnsyh-ania  Uo^viVilfLX  7  ^'''K  occurred  in  the 
Jiad  four  children-;^  r,^'  ^^"""T  ^^''^-^^to.yn.  She 
;\i"R  and  in  «-ood  Sthi  ^.u^T^:  ^^'•>- ••  ''^"  are 
thirty-second  year.  "''^"-'^^  '^^'^"y  '^ow  in  her 


.tm 


8 

witli  tlic  (IcK'tor. 


11'//././.  I. V  os/./:r. 


male,  ai,'-c(l  fil'tv-l 


He  ha 


ivc. 


I  saw  this  patient 


s  enjoyed   o-ood  health,  and   1 


been  able  to  attend  to  his  business  until  reeentl 
about    torty-two    he    be-^-an    t( 
loeomotion' was  <he   iir.st 


^v 


^•et    nervous,      'irre-.ul; 


IKIS 

hen 


alYeeted  about  a 


symptom:    Jiis  speeeh  bee; 


year  ago.     He  will   mak 


or  a  o-nint  in  ])laee  of  words  \vh 


une 
e  use  of  a  nod 


he  has  bee 
to  abandon  bu 


enever  he  ean.     Latel 


lYeonfmed  to^the  house,  and  has  been  obli-ed 
'-■'■y ''''"itable.  and  is  steadily 


sin  ess 


le  IS  \ 


l)assin}4-  into  a  state  of 


dren  : 


ementia.      lie  has  had  five  ehij 


about   thirtv-tl 


"ur  are   Iivin-  and_  in   M-ood   health,   the    old 


nienin.<4-itis  at  sixte 
and  made  the  foil 


iree    years    of   a.^e ;    one    died 


en. 


I 


saw  this 


est 


basilar 


J 


>onv,  weJ 


sion. 


Tl 


-built 


owiiil;-  note 


patient  in  April,  1.S.S9, 


man;  faee  has  an  intelliwnt  ex 


ic  o-ait  IS  very  peeuliar;    he 


)  res- 


side  :  the  movements  "are  in 


sways  from  side  t 


0 


in  ataxie,  but  resemble  rather"  those  of  an  aleo'l 


'L'S  not  use  a  eane  ;    feet 


vi^ular.  very  unlike  tho.se  of 
lolie.     lie 


not  direeted  to  th 
t()<,^ether,  with  h 


e  .u'round 


■e  not  speeially  spread  ;    eve.' 
lie  ean  stand  with  his  heel.- 


IS  eyes  shyt ;  no  movement 


or  arms  when  at  rest,  hut  in  atte 


sof  the  hands 


are  lar<>-e  irr 


mptino-  to  move  ther 


He  h; 


en-ular  sweeps  of  the  arms  and  slioht  tre 


"e 


s  ,^■reat  diffieulty  in  feedintr  him.se 


takes  two  hours 


thouH-h  with 


and 
or  more  at  a  meal.     He  still  e 


mor. 


sometimes 


m  write, 


letter,  but  the  pen,  in'l 


inereasmo-  (lifficulty.    He  .sio-ns  his  name  t 


lip  and  the  si<matu 


or 


niiii'^-  the  letters,  is  oft 


;o  a 


shut    lie   touehes   th 


le  is  ver_\-  irre.i^ular.     With  tl 


en  jerked 


quiel 


Th 


Tl- 


no 


se    or   ear   with    preeision 


ere  is  no  distur 


c   i^-rasp  of   the    hand   i,' 


lie  eyes 
and 


tin<'-lin< 


K 


anee  ol    sensatit 


n 


s   firm  and  strong, 
n,   no  numbness  or 


ce-jerk    slio-htly  inerea.sed;    ankle   el 


not  obtainable.     Pupils  inedi'um  .sixe'-'  1 

on   aceommodation.      Speeeh    is   .slow,   ....    ..„ 

ecjuently  by  the  mterjeetion  'Hem,  ha!'     Th 


f 

liaritv,  his  wif 

m 


e  .savs,  is  o 


'f  e 


onus 

eaet  to  light  and 

and    interrupted 

peeu- 


is 


ent.     The   mental  eondit 


omjxiratively  reeent  develop 


ception    elear.     When    quest 


ion   IS  apparenth 


SiOOC 


oeeasions,  it  .seemed  to  take  h 


ioned,   however,  on 


per- 
several 


o 


ur  wishes.      He  tak 


im  some  time  to  understand 


reads  a  good  de; 

personally  eonduet.s  his  busin'e.ss.' 


es  an  interest  in  what  is  o-oin.r 


on 


partieulaily  the  newspapers.     He  still 


Witl 


m  the  three  \-ears  and  a  half 


preeedi ng  note    he   \\, 
bodih".  > 

Fourth   child,  femal 


since  making  the 


IS  steadily  declined  mentallv^  and 


had  live  chidren. 


e,  aged   fort3'-three,  marr 


One  died  of  scarlet  f 


ied,   has 
"ever;  the  others 


"^  [U-  oU^^  c^J-  '  ^'i^^ 


this  jxitient 

1th,  and  lias 

itly.     Whvn 

Irrc'i^nlar 

L'ch   iK'caniu 

■;<-'  of  a  nod 

•an.     Lately 

•cen  oldiL^vd 

:1  is  steadily 

ad  fi\-c  chil- 

the    oldest 

of    basilar 

Ajiril,  1.S89, 

;'cnt  ex])res- 
■oni  side  to 
ke  tliose  of 
)holic.     lie 
iread  ;    eyes 
.h  his  lieels 
r  tlie  hands 
nove  tliere 
4iit  tremor, 
sometimes 
can  write, 
;  name  to  a 
""ten  jerked 
ii  the  eyes 
L'ision    and 
nd  strong, 
nibness  or 
kle    elonus 
)  lij^ht  and 
nterrai)ted 
"his   peeu- 
t  devclop- 
;ood ;    per- 
)n  several 
nderstand 
>;oin<>;  on; 
He  still 

aking-  the 
itally  and 

Tied,   has 
he  others 


^  y. 


^i' 


o 


/. 


*t^ 


-^Lyl 


<:>>-^^^l 

./ 


7 


Cr^-^-^^,^       \xt^^ 


:/^ 


Atsi-^:^      t-C^'iL^  r^l^  ^2c^«-c.,-*-i_«5^V  .-^^      ^:eAe<_^, 


C^^'-^^-il^^^^t^f^- 


-Wt-*-^ 


CX-U^^-XA^  1 


^  <- 1 


"T^. 


'^''^ 


^/    -  . 


A.£y\J? 


=-'«-*^  --tL-t^/ 


t-c^y^ 


7 


'tyi-£>^\^ 


^ 


H?,    c.'t^v''  /^ce.  :?i^A^^««v&v 


^1 


«-t-»-t^  -/L^l 


<::c/*«<_^, 


^^e 


^e-c^i?' 


^:£^^ 


<^-*Wf^!^ 


/^ 


^^•-t^^^^^^r^  ^ 


r^ 


<-    ^aL 


?^^C^. 


^^^ 


^<^<-'^^-<:^.. 


^  ^^4/-  -^^ 


^e^C 


^''-(.je^^.^L^ 


^r 


4 


C<~-f/ 


X. 


f^-^^^-^i^ 


'^--^^^.^ 


'nC<^^^ 


^ 


<-^-<C 


>£- 


V 


If 


^^  ^^ 


^$-tv^^^_ 


i5t    ,         <^>      '/^'eWi  CUaLOtU 


^.  y^-d:^ 


^--^ 


-M^-^^ 


^^ 


7f. 


--^^  -S-^  c^^^ 


"^3-—^ 


«0^     A.-t-,^_^ 


A 


^'e-^^t^c^ 


C-Cc' 


'<<-e^  ;^  ^^;;.^ 


-6 


'^^'-^^i^icAa,^^ 


^^ 


^>./^^^^ 


<i^^^t't^'~<_,^  ^ 


^^^^ifc:/ 


il 


1  6 '  A^ 


U 


V'V*-^ 


JU^LJ^- 


H. 


! 


1 


hn 


T 


^tA-'V-t, 


rU 


.irc 


hvnii^- 


'^''■'^'^•^^^■^^MYr^/.M./;., 


tlie  oldest 


,  ^lisease  iKis  proofs  lr"'>';^^^'-^^-  I"  this  ease 
tl'y  others  and  iert^lin  n  i^L^^^S'?  /■^'''''''^>'  ^''^"^  '" 
ent,  aeeord.no-  to  the  doetor  s  k  ei^-'fi  ^-'l^'^'c  '^^^""  P'"^''^" 

^ ,         While  sittino-  quie  h    here    n' -''"'^■"'  '"  ^'"'^  '•^'•^P^'^'t. 
f   ments  of  her  lunls  but    u •< • .  •        n   ""  "•'•^■.^ular  n,ove 
'     jerk  of  the  fin^^er,  the  V^l   M  -r  "'"'''"f ',  ''^'-''■^'  ^^'^^'^  '-^  •^Hoht 
'-i^v,  while  speaki,v.  '     e?^":;;;''"l'l  'nove.  f„,d  onecM  ,- 

«.ntmetion  of  ihe  facial 'mileTS      ''■'  ''^   "-'--^"'ar 
le  ton-ne,  and  the  pharvmt'  'l'  „       T  '''  "^*  tremor  of 
^J^e  -rasp  is  ^.ood;   s   e  e-u  n':       ""'r^'''  ''^^'^  ""rniallv; 
'novements,  and  ean  thread  am.  dl' ^'"•^''f  ^'''- ^l^-Iiea'te 
appear  to   be   the   sli<dUest   ,„r' ''''"'  ^''^^'■^' '^''^'«  n(,t 
marked  ehan<,e  appea  S  b)  "^'Z^'T'T      '^^''^  "^^t 
walks    with    the    feet    s,,m    Ji.   <      '""''^ '"  ^^^'i' .s^ait.     She 
■^traioht  line  fairh^vell       he^^-^  ;^^^  '^'y^^^'    '^"^  'l-ollou-s   a 
'■'"^1.  If  i-apidly,  loses     ernl-ee''^;^'  '\^'''^'^  m\.uhy, 

y-t'[i;:?s>^^ 
'T?-;.!^-;^-^;-r"^ti.:::;t^S;^ 

senses  normal;    the  pu         ai"  '  f     '    i '''"•'^^^''""  =    •'^P^'^'^al 

;;  k^■llt  ami  on  aeeo,Sn  ,  bdon  "h    '"^  '^'^^^  and\-eaet 

tile  preeedmcr  note  was  m  nh  1    i      V'"-^  ^^^^'^"^  ^'^'ars  sinee 

ana  the  niusadar  ineolo; S^b ']  a"  '"^  ^"^""^^  ^^P'^"" 
'"^lie  IS  ncnv  confined  to  th,>  i  J^as  become  much  worse 

of  the  time  to  her  bed  ''""■''•  ^^"^^ ''''  '^'^  ^'reater  part 

'ler  death, 


^5i::f/:^^:;--!'-:aged. 


•ged,  at  the  time  of 


par  her  husband  notW  the  b  '  '"•^''"^'  ^J^^^Xv-sceond 
^n  jerkmo-  nKnxMnents  of  the  L^sf I?"'"''?  "-^  ^'^^^  ^^'^^We 
erect  she  had  a  trick  of  ildsinf  h  >  ?'  •'^3"'"R-and  when 
standmj.  upon  the  ball  of  he  "SsT, ''"'',  ''"^^^'^'"'-V  ^"^^1 
of  the  arms  speedily  followed  Woff"^'"'!""'"^"'"^^"^'^ 
i8^o,  she   could  walk  a  mile  n,    f  ^••'^'''' '^^'^" '''-st.  in 

fatigue,  and  would  insist  o     t-  ''  '"''^'''''^   apparent 

mi  e  distant,  repelling  the    u;."-^"  '']  ''^''''■'^''  "^ndv  a 
walk  as  well  as^anothe         \PtS    f  ^^'""^  '^''^  ^"""!^^  "-t 

^"  ""•'^  t^me,  m  walkin.^  her 


H. 


^  lr9  'I 


,l: 


»-t-<7'  '^L::tuZ^ 


^^hJ^^  yL^^c^     ^ 


'  i 


1- 


lO 


UllJJAM   OSI.ER. 


inf, 


with 


body  would  l)c  l)cnt  forward,  her  head   jerk.,.^,  „..„  , 
pcnduhim-likc  motion,  to  and  fro,  and  her  le-^-jTmakins 
sneh  irrej^-iihir  and  lar.L;e  movements  that  slie  would  make 
wide  exeursions  on  the  sidewalk.     A  year  later  she  could 

speech  indi- 


ke 


no  1 


)no-er  ,^-o  out  without  assistance."    llci 


eated  marked  chanj^es  very  early,  in  her  fortieth  v 


an 


d  th 


IS  wa, 


ear. 


s  (in    18.S1    and    iS.Sj)'aceomi)anied  by  ^^-reat 


difhculty  in  swallowinf>-  and  frequentlv  with  c, .„.,,., 
spells  of  stran.^lino-.  She  was  a  most  pitiable  siolu.  Sli 
.suffered  also  from   procidentia  uteri;   yet  in  June.  iSS^. 

was  delivered  of  her  eitrhth 


alarmin;'- 


e 


in  her  forty-third  vear,  she  

child,  which  survived  but  a  few  d 
perfectly  rej-'ular,  h 


avs. 


II 


er  menses  were 


er  menoi)ause  occiirrin<^  in  her  fortv- 


year.     vSix  months  before  her  death  sh 


e  was  con- 


:i.!4-hth 

fined    to  her   bed,   utterly  helpless,  and  was   fed  with 

spoon.     She  was  now  cntirelv  dcmenled. 


a 


II 


cou 


Id 


er  deeji  rellexes   were    rather   exaj^^j^-eratcd.     She 
ibout  the  hou.se  at  night  with  a.s  little  help  as 


in  tile  davli-j-ht.    She  was  exeeedum-1 


Th 


y  irritable  and  cro.ss. 


e  clKircic  movements  sto]i])ed  in  sleei) ;    there  was 


no 

n,  seven 
dl 


are  m 


pai.sv   ot   the   sphincters.     Of   her  eio-lu  childre 
are  living-,  the  oldest  in  her  thirtv-thiVd   veai 
t^-ood  health." 

rosl-MorUui  (about  thirty  hours  after  death  i.  -  Consid- 
ble  wasting;- of  the  bodv;  no  enlaroements  of  joints; 
no  abn«)rmal  position  of  limbs;  face  a't^Tcat  deal  wasted,' 
presentin;^-  several  recent  scars  and  abrasions,  the  result 
of  falls. 


ei 


•al 


The  skull-cap  of    moderate   thickness;    dura    te 


nse 


menin--eal  ve.s.sels  looked  stiff;   longitudinal  sinus  con 
tamed  recent  clots.     On  the  exposed  cortex  cerebri  th 


arachnoid  was  somewhat  turljid  and 


iinu 


.•er.sal 


from  the  pia  by  a  considerable  laver  of  serous 


y  separated 


this  was  especially  maiked  over  the  sulci.     Pacch 
granulations  were  numei 


exudate 


Ionian 


)us  ;    cortical  veins  moderateb 


full.  At  the  base  the  arachnoid  was  turl)id  and  the 
larger  arteries  a  little  stiff;  the  meninges  were  not  e.spe- 
"'^^ '    ""'   "'      pi''i  could  be  stripped  with(mt 


tearing  the  substance.     Superficial  examinati(^n  revealed 
no  areas  of  softenino;,  and   no  special  les 


j:)ec 


lesions  of  he 


mi- 


spheres  or  of  cerebellum.     There  was  general  wa.sting  of 
the    convolutions,  which  were   also,    on    section,    ratlier 


iirm.     The  gi 

thinner  than  normal.      Th 


ly  matterjyas  dark,  and  n\  j^laces  looked 
""  e  crura  presented  no  signs  of 


descending  degeneration;    the    pt)ns   and  medulL-rwere 
natural-looking:    anterior  pyramids  had  a  clear,  normal 


lAh'iirnr.s  of  a/A'o.y/, 


ctioki:.]. 


forln'™S:if,^™™^^^^^  a,„  i,„k.,,t.d  1,.  I.r.  Crav 

w^  m  re  evi^nu  X  t^  "T  ^"'V^^^^'^'-^'-^'-  '^l-'nents 
scopicallv  SeS  ,  s  .^-  'T  ''"'^  ""  f "''""  ^''^'"  "^i^'''-- 
no  's],cci-al  f<.c  lisc!.se       Iv'v'.nTH  "^'f''^^''  ^'^"^^•^'^' 

artcHcs  and  a  shrink': ?'in  Sn"'^']'"-  '""  ^'^^ 
c<)nuia(prMbablv-m    Hi?!^.;.      i         ^'''"^  '^*^   ^'''-'   -'^"terior 

cord  sh</.ved'n;:-in;;;;?,;;;;ri:Lu!ns:"^'-  "'^  ^^^^'"^"^  "^  ^'- 


Til 


c 


m.nbid  a„at„m,-  „f  cl„-„„ii..  d„„x.a  is  il,al  of  a 

ffcr- 


«.;..>io,.ca„d„e„n,,na..  .»;;:--;■:-;;:■  ™- 


The   doctor   writes   that,    prior   to    the   onset  of   the 
orea."  these  patients  and  tl,eir  children  are  in  e     o-  „ 
•UK^^n^ht,  and   the  won.en  are  eomeiy.     The  n.e^^a  ^ 
i^the     a^^oressive.enero-etie.  and  ferocious;    the  women 

cnt>  -„eN  en.      1  here  is  no  history  of  infantile  chorea  in 

llie  pcnod  of  development  of  the  symptoms  covers  a 

vKle  rano:e,  from  the  twent.v-seeond  to  the  sixtieU    vC; 

he  symptoms  have  be.un  earlier  in  the  women  ^aiHn 

L       ,  "'';•   ^  ^  '"^'^;'  ^'^  ''^V^-csent  no  sio-n  of  disease  in  anv 


lAi^ 


J 


I 


If- 


* 


12 


nil.I.l.lM    OSI.I-R 


in 


cmhLTdf  ilic  third  ''cncration.  tl 


cliildrun 


IV    past    tliirty-five.       TIici 


'loiijr-h  several  of  the 


ivniarkablu    inscnsil)ility  to  pain    in   th 


e    seems    to   he 


th 


fall  about  and  l)ruise 
plaint.     Shortly  befc 
cast-iron  key,  lodi-ed  in  the  d 


cse  eases 


tl 


ley 


cniselves  sovereh-  without  eon 


broke  it,  n, 


iturallv  l)ruisin; 


much;    l)ul  of  this  she  I 


re  the  death  of  No.  4,  she  struck 

>r-lock,  with  her  hand  and 
in.!^-  her  hand  very 


and  maim 


nnel 


c  and  the  mother  of  tl 


00k    no   notice  what 


ever. 


showed   much 


the  second   i-enerat 


i'reatcr  muscular  vi 


icse  patients  kept  about  -nd 


"■or 


than  memljers  of 


apparently  pr 
the  disease 


ion,  in  wliom,  too,  tlie  d 


ementia  has 


■oRi-cssed   more   rai)idly.     'J^he   pro-ress  of 


ments  are  l)ut   littl 


nuieh   excited    1 


i.s  marked  b) 

e  under  control  of  the   >vill  and  :: 


n"cat  emaciation;    th 


e  move- 


)y  volition.     When   stand 


mu.scles  are  mucli  affected  wh 
ancinn-  the  sjiinal  column  and  the  head 


nu 


onlv  th( 


ire 
)se 


stop  durin 
sleencrs 


.U'   slcci). 


Th 


\ni\ 


Tl 


-an  indispositi<m  to  articulate 


ich   are  concerned  in  bal- 

the  movements 

CSC  patients  have  all  been  H<,dit 

sic,  but  muscular 


le  s])cech  defect  is  not  ai)ha 


on   ac 


m 

tom 


movino-   the    mu.scles.      I 


n    case    X 


count  of  difliculty 


s   were   verv   simik 


paraK'sis. 


U"    to    tho.se    of 


4    tl 


ic    symj). 


a   ease  of   bulb; 


M:ni:k  l.\Mll,^•. 

So  far  as  can  be  a.seertaincd  onlv  f. .ur  members  of  the 
family  have  been  affected,  namely :  mother  and  three  ehil 
dren,  one  of  whom  was  our  jiatient,  Peter. 

I.  The  mother,  a  (German,  is  stated  to  have  had  trouble 
ot  the  same  kind  as  that  which   ]>eter  has.     For  manv 
years  she  made  wild  inco-ordinate  movements  with  her 
arms,  and  toward  the  end  of  her  life  she  c.mld     "t  ea 
aW>  and  had  to  be  fed.     Her  mind,  also,  \..l^^ 
^\cak.      the  exact   duration  of  the   dise-is(>   i',-,    h,.,.  „     -^ 
-uld  not  be  obtained,  but  it  extended  ove^sJ^i'VJ;^ 
She  IS  .said  to  have  died  of  heart  disease.     She  has  one 
brother   ivin^.,  aoed  eiohty-three,  who  is  said  to  have  do 
di.sease  but  Dr.  Simon  visited  him  and  retoorts  t   at  he   s 
only  .sub,ect  to  ordinary  senile  tremor.     No    nf  S  iti<  n 
IS  available  with  reference  to  her  familv      Ifer  n Sen 


"-^a^mri-m«mBmm:i 


iymiyk^ 


^mmm 


'••/A-//^/yA;v  OF  ruA'o.y.r  r;ro,,,. 


name   was  SchmirU      yi      ,     ,  '"  ' ''  U 

chorea  (IeveI<,jH d.  be<,nnnim     „  "'  ''';'"  '''^'^^  ^''i"''''  the 

''and  not  ced  tI^-l^  ^k?   f       -^    "  "•-'  -''"'n'^  first      ir,.,-  i, 

^  itus'  danee.  "'''"'"^  ^'^-'J^^'^I  very  much   \\k^  st" 

.      3-  Nicholas  Neiter  -irr,.,!     i  . 

>"S:  at  Kd^ewoocl  Y^inS^  ^^;:;%/<;'"'^;  'blacksmith,  liv 
me  by  Dr.  Chas.  S  mo     whn  ,      '  ^^'^-     ^^^'  ^^■''•^  seen  f  ," 
subject  to  the  diseai   as  he  d'^'^T'"''  ^^''''  ^'^  ''^  evident  v 
nate  movements  of  the  li^ s  arm?"  -'iT'^''"^  '"--      - 
'"'.he  IS  inclined  to  be  child[    ' '   'T    ^''''''--     ^^^^ntallv 
e  regards  himself,  howex^r  a  In  r'  '"  ^''^  emotional.' 
health  and  not  affected  in  a,  v  w'     '^  ^'^^^^ition  of  perfec 
4-  Peter  Neiter,  a<red  fiE  '?/  ''l^'"''  ^'-other  J'^ter 
;vas  admitted  to  lohnhYopW^R     '  .?7:«''^"- ^  butci'- 
1  aticnt  has  been  in  th  ,  Joum^^  iSno' 

^vays  enjoyed  good  health  w"  ,  "''"^'  ^'^5°-     He  has  a? 
-hen  he  first  c?,ne  tl^  t^  ^ci  ^^^^  f  ^^Pt^on  of  m^.H  [ 
He  dates  his  present  tronb      J^  '  ^'''■'  "'^^  'i'^''  SN-phiHs 
'"testinal  disturbance  ekhvf"'  '""  ^^"'-^^^J^'  "f'is  ro' 
the  drinking  „f  lan'e  can     i?      "'/'^'"'  ^^''"^h  foHowed 
this  time  he^had  alsT,  pS "  f  ^l^  if  'T^  ^^naonadc      a 
the  occurrence  of  somVth  n/r  1,       ,-''^''^^ '  ""''''  '^e  speaks  of 
cannon.     The  movements  lo".'^' '"  '"'^  ^odv  like  • 

;  -o^^r-heatingamSnggSrcilSs  '^  ^^^^  ^- 
.^tart  at  any  particular  part  of  th^  ll  i  S '  "^  ^'^'>'  ^^'^1  not 
'••'>m  the  outset.     Thcvhnv,  ?'^>;;^"t  were  general 

particularly  when  volmuarv  If ''''^"^^">^  become^vor;e 
are  severe  enough  to  Snt  hi^T"''  '''''  '''^'^^-    They 


.  t 


I 


M 


ir //./../.  I. )f  OS/. /■:/,: 


r! 


ICmotion  Of  frij^ht  always  cxaj^j^c rates  tlie  movcmcMits. 
He  has  not  had  headaches;  has  as  a  rule  slept  well.  His 
appetite  has  been  j^-ood  and  j^eiieral  health  excellent. 
J'^ver  since  the  attack,  eif^ht  years  ai^o.  he  has  been  liable 
to  a  recurrence  of  the  vomiting  whenever  he  takes  cold 
drinks.  He  says  his  memory  is  quite  };'()od.  He  does 
not  think  that  his  speech  has  lieen  affected. 

/'/iSi///  C'(>//i/i//;>;/.  Thv  jiatient  is  a  larj^'c,  well-nour- 
ished, well-built  man.  The  face  in  rei:)ose  looks  intelli- 
i^'cnt,  but  on  smiiii)if-,  the  exi^ression  is  fatuous.  He 
answers  all  (juestions  readily  and  freely;  <^ives  a  .t^ood 
account  of  his  condition,  and  it  is  more  in  his  expression 
and  i^eneral  behaviour  that  an  indication  is  found  of 
mental  impairment. 

When  sitting-  in  a  chair,  at  ease,  the  arms  and  hands 
are  in  more  or  less  constant  irregular  motion.  The 
iinj^ers  are  extended  and  tlexed  alternately;  sometimes 
only  one.  sometimes  the  entire  .set.  At  other  times  the 
whole  hand  will  be  lifted  or  there  are  constant  move- 
ments of  pronation  or  of  supination,  i'or  half  a  minute 
or  .s(j  they  may  be  perfectly  motionless.  The  head  and 
trunk  present  occasional  slow  movements ;  in  the  latter 
more  of  a  swavini^'  character.  The  lc<;\s  jerk  ir'\.-';;ularly 
and  the  feet  arc  llexed  or  exteitded  ;  but  the  mo"emcnts 
are  not  so  freciuent  as  in  the  arms.  The  face  in  repose 
is  usually  motionless,  but  the  lips  are  occasionally  brought 
together  more  tij^-htly  and  the  chin  elevated  or  depressed. 
There  is  an  occasional  mtn-cment  of  the  zvj^'omatic  and 
of  the  frontal  muscles.  He  puts  out  the  tonj^ue,  witli 
tolerably  active  associated  movements  of  the  face,  and  it 
is  usually  ({uiekly  withdrawn  or  rolled  from  side  to  side. 
It  is  impossible  for  him  to  hold  it  out  for  any  len^^lh  of 
time.  There  are  no  in-egular  movements  of  the  palate 
muscles. 

He  walks  with  a  curious  irregular  gait,  displaying  dis- 
tinct inco-ordination.  swaying  as  he  goes,  h  sitating  a 
moment  in  a  step,  keeping  the  arms  out  from  the  bodv 
and  in  constant  motion.  The  legs  are  spread  wide  apart ; 
steps  arc  unequal  in  length  and  he  seems  rather  to  drag 
the  feet.     He  stands  well  with  the  heels  clo.se  together. 

There  is  a  suggestion  of  stiffne.ss  about  the  g;iit  and 
about  the  way  in  which  he  uses  his  legs. 

vSen.sation  is  unaffected.  The  deep  reflexes  are  in- 
creased. There  is  slight  ankle  clonus,  exaggerated  knee- 
jerk,  and  slight  increase  in  arm-retlexes. 

The   special   senses   are   unimpaired.     Pupils  are  ol 


innvcmcnts. 
»t  well.  His 
1  excellent. 
!  been  liable 
•  takes  eold 
1.     He  does 

_',  well-noiir- 
ooks  intelli- 
tuous.  lie 
ives  a  j^ood 
!  expression 
is   found  of 

and  hands 
otion.  The 
;  sometimes 
r  times  the 
-;tant  move- 
If  a  minute 
e  head  and 
n  the  latter 

ir'V'^ularly 
mo'-ements 
e  in  I'epose 
:illybrou<^ht 
r  depressed. 
;-omatie  and 
oni^ue,  with 

face,  and  it 
side  to  side, 
y  lenoih  of 
■  the  palate 


playin*^  dis- 
^  sitating-  a 
n  the  bodv 
wide  apart ; 
her  to  dra^' 
^e  together. 
lie  g'ait  and 

!xes  are  in- 
stated knee- 


ipil.s 


are  ol 


/■.//.■//:• //A-.v  or  ruR 


"ie<liuin  size  -  tli 


'y'oxic  c/io /,•/:.  I 


reaet  to  light  and 


•-'  '■■gilt  a  little-  1, 


tagi, 


"■^^--er  than  the  I 


uis. 


^irine  show 


He  I 


'"]  'i<-vomniodation;   tl 


'•'>^  n(.  fever;    l),n\x.] 


•^  IK'  speeial  ehan 


■s  are  i-i 


^•ft  :   thev 
■e  is  no  nv.s. 


-;'es. 


lei 


'f^iilar,  and  i\ 


le 


'•L'P'Tt   of  eases  of  the   1 


<'<'es  not   afford 


th 


oth 


iL'iv  are  jjrobl 


iere(h'larv  { 
■'  very  wide  se.,pe   for  ,1 


or  and   t 


'<-''ns  ill   the  relat 


orni  of  ehorea 
i.^cussidti;    j„|t 


literature 

point   (1 


o  ehor 


ea   miiioi', 


!""<"■  tlK'  forms  tueaeh 


«-re,ssive   ehoi 


'•"■'Kilt,  are    still   f 
view  may  ])e  \-erv  briellv 


\\'hieh.   if   I    I 


irom 


lave    read    tl 


•^i-'tlled.       M 


lisorders   a.s.soeiated 


'<-'•'-   '-^  a  maladv  d 


•■stated:    fh 


le 
>■   own 


wntres  or  path  1 


with    coarse 


'■^tinet   from  t 


ronic 


pro- 


lesions 


i<-'  x'arious 


ti"n  w-hieh  (like  f 


^n-'wu  as  symptomatic  el 


<'l    th 


famil 


les  or  in  si 


ormsof  museul 


lorea- 


"•regular,  ineo-ord 


".^■'L'  individual 


'11'  atroph\-)  m, 


li.'^turban 
"aeult 


<-'<-'.s,  and 


mate  movement 


■'^.  and  is  eh 


^  motor 
an  affee- 
'>■  "ccur  in 


les. 


eh 


Thi 


Pi 


•'^.  a  reel  in 


•"^•i-e.ssive  imj,airment 


'I'aeterized  bv 
.^•.^ait,  speech 


"I'ea  minor,  bei 
of  iM-iedreich'sat; 


"lovciiients   d 


iher  from    il 


"'  the  mental 


1.^;  slower,  and  resembl 


i"se    <,ij(^rx 


tt-T  of  the  for 


^-\'ia,  without  t 


to  the 


iner  disease.     M 


le  bru 


i"J4'  rather  th 


III 
( )se 


movements  of  d 


ore  over, 


■^qiie.  jerkv  char 


m  strikin; 


;ic 


gressive  chore, 


-V  cert 


I   are 


""•^•;i  minor,  those  of  eh 


ai 


n  number  of  tl 


sometimes  in/ii, 


t-'ontrast 
i""nic  pro- 


le  cases  of  eh 


"■"Kin  infancy  and  childhood 


but 


t.meed  by  the  will 
I'onie  chorea  b 


a  very  much  lar 


parapleg-ia  m-  dipl 


■«vr  number  are  in'st 


JL'long-  to  this  cates 


'onns  of  chorea  min 


<-\^'ia;  while  othe 


:mces  of 


Ch 
wholl 
hav 


or, 


i"s  rei)i-e.scnt  a 


egin- 
;ory, 
■ipastie 
nonialous 


ronie 


Pi 


•o^-ressive    chorea  is,   I   bel 


apait  from  the  affeeticmd 


leve,  a   d 


111^  nothin 


^•ourse  of  acute  ehor 


y  in  common  with  it  but  th 


escribed  by  S.vdenh 


isease 


:im. 


tile  arthritis,  th 


■fa  minor,  the 


<-'  name.     The 


fre 


■quency  of  endoeard 


e  seasonal    relati 


incidence  in  child 


ent  characters  of 


iti,' 


•t( 


ons.  the   extr, 


:iordi 


ren, 
nary 


th 


e  movements   ab 


«ay  nothingr  of  tJie  diffei'. 


I^epanite  it  as  a  Well-defined  affe 
<^n  a  virus  as  yet  unknown. 


lOV 


-tion,  depend 


e    referred    to- 


rn y 


y  possibly 


'^-a2i^«^<t«aiiS^4^.% 


•x 


X  >i  j» 


S!^T:^!^!^!^l!^nu^^    ^,,,^,^  j^^^^^^^  ^^^^ 


18!)3.) 


NOTK  ON  ARSKNICAI.  NKIIRITIS 

POLLOWINfJ   TMK 

•'«E"t-KOWM.:U'.S  SOLUTION  (,4  ,-,1^,8),. 


Bv  Wm.  Oslbr,  M.D..  F.  R.  c.  p.,  j. 


lONDON. 


During  the  first  few  years  of  ,„.a„r       t 
"«i"«  arsenic  somewhat  s  ar  nl  r      "'"'  '"  '^*'  ''«^'"'  °f 

Hramwell's  paper  in    877        f.^'         "'^'"''  "'^  ^PP'^'^rance  of 

'0  "-  i'  ™or:  free.,,  anT  l  "  ^I: t^  "'^  ^^^-''^ 
anaemia,  in  leuksemia  in  rin,J  ,b    -    >  "  ''"'''""^  '^^'-m^  of 

have  used  it  i„  w^Jm " ,"  ^'T,  V'^^"^*^'  ^""^  «'-^«*  ">inor  I 
^een  to  begin  with  tw  of  th  /:  t^^  '""•  '^^  ^"'^  ^- 
«raduall,  increase  the  dose  ^r.     rfi'^^^  "  ^^^'  ^^ 

patient  took  ten,  fifteen  or  '    ., T  ^  ^^^^  "»f''  '^e 

tl'ree  times  a  dal.  I  Iflrr.d?  ™""u"^'  '^  ^""'«^'«  «°'"'ion 
either  itching  of  the  sk.  i"  f '?"  '^'  P'^^'"'"«'^«'  ««"-'«. 
or  diarrhoea.'  The  ^a'^.'th  ^h  :?;:;  ^^^  ^^' ^°"'''"«' 
varies  in  different  individLrs  atl  ""  '"^^  ^^"^^'^^^^ 

who  bear  the  drug  best  seeZt  """""'«  ^^''^^  'hose 

'argost  doses  I  hate  g  e Tw"  iTT"  '':.  ""'  "P'^'^'"  l'^^ 
in  which  the  patient  had  taken  ^rT  ^^^"'''■<>»«  ««^«>ia, 
'he  greatest  benefit  for  se  !,  ^  f  "  ^"■""'^>'  ^"^^"^  ^''^ 
-'"tion  three  times  da  ;/ k  7"'^  """"'^  ^^  *^°-'«r'« 
thirty  minims  three  imesa'davl  .T'^'  '"  ^'^  -'«P«« 
had  an  attack  of  itchirof  th^e'e  rf  '^'  '"^  '^^  *  ^^^^  h« 
eye  brows.  ^       "^'  '^^  '"^«'  »"d  «dema  over  the 


In  the   chorea  minor  of  children,  who,  as  is   well  linown, 
stand  arsenic   well,  it  is   a   common    experience  to    find   that 
twelve  and  fifteen  minims  of  the  liquor  arsenicalis  may  be  civen 
daily  without  ill   effects.     Until   two  years  ago,  though  I  had 
often  seen  the  symptoms  of  saturation  above  referred  to,  I  had 
never  seen  any  serious  toxic  symptoms  referable  to  the  nervous 
system,  but  we   had   at   that  time  in  the  ward  a  patient  witli 
pernicious  anremia  who  had  taken  for  a  long  time  large  doses 
of  Fowler's  solution,  and  under  its  use  had  feelings  of  numbness 
and  tingling  in  the  feet  and  legs,  which  we  thought  might  he 
due  to  the  arsenic.     This  may  not,  however,  have  been  so,  since 
these   advanced   cases  not  infrequently  have   sclerosis  of  the 
posterior  columns  of  the  cord,  in  connection  with  which  loss  of 
the  knee  jerk  and  sensory  changes  in  the  legs  may  develop.     1 
have  repeatedly  in  my  clinics  and  ward  class  talks  referred  to 
the  apparent  harmlessness,  so  far  as  my  experience  went,  of 
Fowler's  solution. 

On  October  25th,  1892,  the  patient  before  you  was  adrjitted 
to  my  wards  with   Hodgkin's  disease,  the  cervical,  axillary, 
and   inguinal  groups   of  glands  being  involved.     Having  had 
under   observation  for  now  nearly  four    years  a  case  of  this 
disease,  which  has  been  remarkably  benefited  by  the  prolonged 
use  of  Fowler's  solution  taken  at  intervals,  we  naturally  placed 
this  man  upon  the  same  drug      The  details  of  his  case,  so  far 
as  they  relate  to  the  lymphatic  disorder  do  not  concern  us. 
The  arsenic  was  begun  on  October  27th,  given  as  Fowler's 
solution,   and  gradually  increased.     He  took  it  on   the  first 
occasion  for  ten  days  ;  it  was  then  resumed  on  November  14tli, 
and  in  two  weeks  the  dose  reached  fifteen  minims  three  times  a 
day.     Towards  the  end  of  November  it  was  noted  that  his  skin, 
which  was  naturally  of  a  somewhat  dark  colour,  had  a  much 
deeper  tint,   and   that  of   the   abdomen    was  very   distinctly 
hronzeil.     Throughout  the   month  of  Decembe     i /^  did  not  do 
well.     The  arsenic  was  stopped  on  the  19th,  a  d  '-egun  again 
on  the  27th.     From  the  outset  the  patient  has  had  that  inter- 
esting feature  in  many  cases  of  Hodgkin's  disease,  an  intermit- 
tent pyrexia,  and  as  may  be  seen  by  his  last  week's  chart,  the 


lfr333S3^«J&iii;'£.'d-■,a^^^af^i:'<wt*M*«  '^t" 


8 

temperature  rises  every  afternnnn  ar,^ 

The   pigmentation  seeme'l  ?  '''"'"«  ''  ^^°»'  10^°- 

Twice  during  the  fist":  Tonir^T-  ''""^'°"'  ^^^^^er. 
was  slight  di^rrh^a,  :,•:;.  Z^^^^^  -^^J"^  ^<^^VM  there 
tlie  middle  of  January  it  wfl«  n..      ,  7     ?        ^'''^"'"-    ^^l^out 

«oh  a„.  „a.e„z:;r3:c"  u^izr"""  "- 

Bnglish,  and  a,  there  „s,  „„  „„:  :„  ',     '  "  f  "I"'  'P''''"'g  "0 

lion  the,  deserved.     The  n,„,i  IT     ,  ""'  "'=  ""«"■ 

.l.e.e„.,tive„..,  o„  prL,„:  '  '       li'^^rl 'l'''  '™=  "" 
10  bo  painfal,  but  if,  r„r  oxamnio    h.  !  ''  ""'  Wear 

pectoral  muscle  lifted    or  the    ,',    K  ."f  =™'""'-  "  "■« 

•ear,  came  into  his  eye,      bI  t     td"°of  f  "°  "'"""  ""^ 
»ith  much  difficulty  and  Jl  .         ,  '""'"'>■  '">  ""'ked 

closet.     He  has  n„  ra  ,v    „  fh  "  «°  '""'  ''''  "^l  '»  »■» 

good  deal,  but  the  le    t   „  t  ra"'?' '"'  "'"""•  "-""'  ' 

.-, »ithi„  the  past  trith,  :;eer\t'r''''"r 

»hich  were  present  on  Januar,  lOih   .  1      "'  ■'"'"' 

On  February  2nd    D      hL  ,  T  "'"'"'■ 

•Wit,  of  the  nerve,  of  the  le  li"""""'    "">  '"<"«  e«i'- 

reote  wa,  „„,»   m.  and    h'  '™""'"  '°  '°"'  ™- 

galvanic  ,timulati„„  wu  iec^edlv  slo""  '"T?  ""'""'"'^  "'« 
larger,  .as  at  least  e,,ual !:;  f^  o""  t  '"'  ™f ''  ''  ""' 
rn  the  arms  is  not  so  8trilm„l„  j- '       /  ' ,  ""^  """eular  power 

feeble  in  comparison  wt  ^      i  'rr^'^J""''  ""  >"""  " 
of  the  muscles  does  not  nnn.o        u  ^yper  sensitiveness 

Bee»ee„the2;r;orCni::",:r7r-   . 

patient  took  54  3I  m  i«  '.  .V,  "''^  ^^f'' of  January,  this 
e^juivalent  to  about  16^  ..ain.  .(1  ■'  P"'""''*  ^rsenitis, 
-ent,-five  da,s  there  we'e  f  rtr"'."  ""'•  """^'"^  '^^^ 
was  omitted.  The  marked  '  ""''''"  ^^^«  ■»  ^^hich  the  drug 
pai-ent  of  musclar;:  /"JTh:'"^'^^'  ""^  «-^-'  - 
the  symptoms  indicate  verv  clear  v  he  '"'T'T  ''''''''''  '' 
nature  of  the  affection  •  and  h„ .  1  )  r^'P^""''  '"^  "^""''° 
in  which,  as  in  cancer  ;r    ub S  2"  '"  ^^''^^"'«  -^^^-'^^ 

Ft  it  seems  more   rational   to"     Lr^^  ™'''  '^"'^P' 

to  attribute   It  to  the  somewhat 


J 


li 


t-i   s 


^' 


prolonged  use  of  the  arsenic,  more  particularly  as  he  has  had 
also  another  striking  feature  of  arsenical  poisoning,  namely, 
pigmentation  of  the  skin. 

Arsenical  neuritis    from    accidental    poisoning  is  not    very 
uncommon.     Less    commonly   it  results  from  accidental  con- 
tamination in  certain  occupations.     It  is  claimed  by  Folsom. 
Putnam,  and  others  in  Boston,  that  cases  may  be  of  "  domestic 
origin,"  that  is,  due  to  the  absorption  of  extremely  small  quan- 
tities of  arsenic   with  the  dust  from  wall  papers,  carpets,  or 
curtains.     Cases  such  as  the  one  reported  this  evening,  in  which 
the  toxic  symptoms   have  developed    in   consequence    of  the 
administration  of  arsenic  as  a  medicine  are  in  reality  extremely 
rare.     A  few  years  ago  Dr.  J.  J  Putnam  collected  a  series  of 
cases  in  which  serious  poisonous  effects  had  followed  the  lon<^ 
continued  use  of  medicinal  doses.     A  majority  of  them  cannot 
be  said  to  be  very  satisfactory,  as  the  reports  are  imperfect  as 
to  the  amount  taken  and  as    to  the  symptoms.     Among  the 
cases  referred  to  are,  however,  some  which  would  indicate  very 
clearly  that  the  prolonged  use  of  even  moderate  doses  may  cause 
symptoms  of  a  widespread  neuritis.     Individual  idiosyncrasy 
plays,  no  doubt,  an  important  role  ;  tolerance  may  as  a  rule  be 
established,  as  with  the  Styrian  arsenic  eaters,  but  such  cases 
as  the  one  before  you  show  that  we  must  be  on  our  guard  in 
the  protracted  administration  of  the  drug. 


irly  as  he  has  had 
•oiaoning,  namely, 

aing  is  not  very 
n  accidental  con- 
aimed  by  Folsom. 
^  be  of  "  domestic 
emely  small  quan- 
ipers,  carpets,  or 
evening,  in  which 
isequence  of  the 
reality  extremely 
llected  a  series  of 

followed  the  lonj^ 
y  of  them  cannot 

are  imperfect  as 
'ms.  Among  the 
mid  indicate  very 
?  doses  may  cause 
iual  idiosyncrasy 

may  as  a  rule  be 
■8,  but  such  cases 

on  our  guard  in 


UNIVERSITY 
|lEDIC/^L     "WaqAZINE. 

'  'inillU|.>TArF 

:-sB  ^^^^  ss?^- 


c  v:  >cx  r 


APRIL,;  isfea 


NO.K  O.  .  «,„._^^^^^^^^^ 

•  - 

Bv  W11.1.1AM  OsLBR,  M.D., 

-rores^r  of  Medieiue  i„  th.  Johns  Hop.i„,  cler.ity. 


I 


1  j! 


'■     i     is 


•N'OTIC  ON-  A  ^'=';'ARK^BI.K  HOUSE  K.>,r,EM,C  OF 
1  iPHOID  FEVER. 

BV  WUJJAM  OstER,    M.D., 


ITofcsorofMecIicinei,,, he  Johns 


Hopkins  University. 


Grac^  Md"!'"  ^'e  a'c'a;e'i,rr'   "7  ^^"-^'"g^-'.  «bove   Havre  de 
typiioid  fever:  ^n'^^-kable  history  of  a  house   epidemic   of 

oce.n^;?^y!";;l:hJ^-w:?:i^Ldif " ':  ^^^^^  ^"  ^"^"--  ^^^ 

his  home  in  Baltimore  Augu  t  g  fnd  '^  ™^^^"^-  "e  returned  to 
mother's  home,  and  was  ill  for  J;  ,  "  '^'  '^'^  '^"^^  ^'^'^  to  his 
and  had.  according  Toth  d  e^  ""'^^'^  '""'^^  ^"'^  ^'^''-""^ 
fever.  There  had  been  no  p^e^ilul  ^  T"'"'  '^"^^"^  "^  ^>Pb-^ 
house,  and  it  is  perfectly  clear  Ztl!^    7'"^  ''''  '^""^"^^^  '"  the 

Cask  II.-HIs  wife   a    p    f  h     '  '''  ''"'^  '^'^^^  ^^'^'^  ""Parted, 
of  September  with  typhoid  feve';  we'll  n,"^'  T^  '^'''"  ^'^  "^^"'  ^^^  ^9th 
At  the  end  of  four  weeks  she  was  I    'jr^';'  ^^^^'^  ^^^  -^°  to  :o4^ 

rhages,  and  again  was  ill  six  weeks   but  uldt  TT'  """''''  '^'  '^»«'- 
Case  iri.-His  sister   M   I  .  "'^'"'-^tely  recovered. 

^9th  of  September,  had  a  v;rv  bfd'-X,  td""  f^f  ''  ^'^^"^  '^^ 
Cask  IV.— j.  b    a  sni^r  ,„  a  sradiwHy  recovered. 

..»%  had.  je.e„„;;:4e:::;vr^^^^^       a„d .... 

■  "  ■~'°""  "■■  ''''  '•  ™  °^  W„.  E.  rcase  I),  ca„.e  .i.„  his 


(I 


i .  ; 


2  William  Osier. 

mother  from  Baltimore,  and  was  taken  ill  about  the  third  week  in  Sej;- 
tember.  He  had  a  mild  attack,  with  fever,  abdominal  symptoms,  and 
well-marked  rose  spots. 

Cash  VI.— John  B.,  aged  35;  fever  began  toward  the  end  of  Sep 
tember.  He  had  headaches,  diarrhea,  and  a  tolerably  sharp  attack. 
Convalescence  began  about  October  17th;  the  temperature  remained 
about  normal  until  October  24th,  then  he  had  a  definite  relapse,  with 
fever  ranging  to  104°  and  105^  From  November  8th  until  the 
14th  there  was  a  period  of  apyrexia,  and  then  the  temperature  rose 
again,  &iid  I  saw  him  on  the  26th  in  what  appears  to  be  a  second  relapse 
The  temperature  has  been  up  to  103°  and  104°,  and  on  several  occa- 
sions 105'.  On  the  25th,  for  instance,  temperature  range  was  between 
101°  and  105^.  He  has  been  delirious,  and  has  had  several  chills; 
great  pain  in  his  legs,  and  very  great  tenderness  of  feet,  especially  on 
the  soles. 

This  case  was  away  from  the  house  at  Annapolis  a  short  time,  am! 
was  the  last  to  take  the  fever. 

Cask  VII.— Nurse  T.,  taken  ill  on  the  17th  of  October,  and  was 
removed  to  the  Homeopathic  Hospital  in  Baltimore,  where  she  had  a 
well -characterized  attack  of  typhoid  fever,  of  which  she  died.  She 
had  been  in  the  house  forty-two  days. 

Case  VIII.— Colored  nurse  of  child;  was  taken  ill  about  the  loth 
of  October,  went  to  Baltimore,  and  had  a  definite  attack  of  typhoid 
fever  and  died.     She  had  been  in  the  house  twenty-six  days. 

Case  IX. — Mi.ss  G.,  nurse,  had  been  in  the  ho.,.se  fortv-two  days, 
and  was  taken  to  Philadelphia,  ill  with  typhoid  fever,  and  died  in  the 
third  week  of  the  attack. 

Case  X. — B.  B.,  a  sister,  had  also,  according  to  the  doctor's 
description,  typhoid  fever,  but  she  kept  about  the  house,  and  would 
not  go  to  bed  for  any  length  of  time. 

During  the  months  of  August,  September,  October  and  November 
there  were  ten  cases  and  four  deaths. 

The  house,  a  comfortable,  old-fashioned,  square  stone  building,  is 
situated  on  a  ridge  in  the  beautiful  rolling  district  of  Hartford  County, 
only  a  few  miles  from  the  Susquehanna  River.  In  front  of  the  house 
the  ground  slopes  rapidly  toward  the  roadway,  which  runs  ilong  a 
narrow  valley.  At  the  back  of  the  house  the  land  slopes  more 
gradually.  At  a  distance  of  about  seventy-eight  yards  in  front  and 
to  the  left  of  the  stone  house,  and  about  two-thirds  of  the  way  down 
the  hill,  is  a  comfortable  frame  house,  occupied  by  the  tenant,  with  a 
family  of  nine,  of  ages  from  14  to  85.  About  seventy  yards  further 
down  the  valley,  close  to  the  roadway,  is  a  spring  of  clear  water,  close 
to  which  is  erected  the  "spring  house  "  for  dairy  purposes. 


)lis  a  short  time,  aiir 


:ober  and  November 


RemarkaSfe  House  HpUe.nic  of  Typ„oi,  J^erer. 

Opening  from  the  kitchen  of  Mr  n'  -  i 
extension,  there  ,s  a  covered  stonn  n  u  ?'"'  ^^'""^  ''«  ^  ^-shaped 

i^  a  cistern,  square,  wUhT depth  o  ''''.''\'''^'-''^  '^-  Aoor  of  which 
bottom  of  which  is  ten  fLt  belowth  '  "7  "f  "''^^  °^  ^^"  '''''  the 
and  was  last  cleaned  ahou  X  ^''t?"""-  ^^^— ^^d- 
water  from  the  roof  and  at  o>ie  L'^^  ^^"  '^''^^'■"  ^^^'^^^ts  ,he 
spring,  which  was  pumped  up  by  ITJ^T'"'''  T''  --  "- 
ago.  "^         '    "^  '^  ^'^^     This  was  abandoned  years 

Immediately  behind  the  kitchen  .,  v 
feet,  is  a  woodshed,  and  a  orivr  ,^  '•  '^''^'"""  °^  ^^out  twenty 
ground  behind  the  C,:  .  T  e^oUom' f'lh^'"'^'  "^  ^^^  ^'^^^  °^ 
the  ground.  The  difference  in  LveTb  "1  *'  ^''^^'^  °"  ''^^  ''^'''  "^ 
and  the  top  of  the  privy  is  M  B  hinkT  K  '  '""^"^  "^  *^^  -^^"" 
tically  is  the  situation  o'f  the  surfoun  wl  T^  T  '"• "  '^'^''^  P^^ 
comfortable  ;  the  rooms  are  larje  .!  d  i  ^°"'"  ''^^'^  '"^'^^  ^^ 

whatever  in  their  arrangemen  ttTc.]  V  '°"^'""'^"^-     There  is  nothing 

Dr.  Sappington  wrlteTthVt  ^f^'^^l'^^^f  ^--^^-t. 
brother,  who  did  not  go  tto  the    t,    ^"^^'^°'^  ^°"-«ted  of  another 
drank  the  water,  as  did  also  a  tlo  ed  Z'""''  "T'  '''  ^^^  ^°°^  -^ 
(Mrs.  B.),  also  Dr.  Sappington  dra.lfr  7  T?  '''  '''°  '^''  "^^'^er 
often  had  his  dinner  at  the  hoTse      a  /'?     °-       '^""^  ^'^^^-  ^"^ 

------week,:-u^^;:tr5;ir-:- 

one  ^";^  "c^s:  ni^^^^r  r  ;^  ^-  ^^^-^  -  -- 

fault,  since  living  close  by  and  usinl  th  .  ^'?^  '""'"''  ^^^  "^^  at 
of  the  tenant,  every  member  of  h-?  '"^'"'  ^'''^'  ^^^«  '^^  ^^nnly 
remain,  either  the  food  suppLs  or  the  k •".'''''•  ''"°  ^^^^-^^'-' 
way  infected  from  the  fistSsrwhi  ,,"'"'"'' ^^^^  ^"  ««"^e 
likely  view,  or  the  disease  Lsp^'trr-V''  ''  '^  '^^  ^^^  ^-^ 
which  Dr.  Sappington  holdr^ery  firmTv   but "^  h f  T"^^^'""'  ^  ^^^ 

washmg  the  kitchen  utensils  CuDon  wWi,  '''^*^'  '''^'''  "^^^  for 


-I'll   <^,<l;:_T'^ 


CASES 


OF 


SUB.PHRHNIC  ABSCE 


BY 


WILLIAM  OSLER,  MD 


^/^  Canai^tnn  PracHhoner." 


TORONTO : 

The;,   e.  Bryant  Compavv    r 

'  "uci;, 

1893. 


r 


'H 


CAS  E  s 


OK 


SUB-PHRKN,c  AHSCHSS 


II V 


WILLIAM  OSLER,  M  d 


S"N.VEKS,^^,    „A,.-,,„,.,« 


i 


Till-: 


iOKONTO: 


i:.    lik 


VANT  C 


"■^"'ANv,  Limited. 


I    ' 


i;  1 


CASRS  OK  SUIM.HRKNIC  ARSCKSS.* 


'<v  \\'II.l.IA^f  Osi.KR,  M  I) 

T-HE  foll,n  .""''"'"'"'""'"'•  ^"''- "op"- i^"<v-i,,;  ,„,,.,■„„.,. 
I    lib  followinK  cases  illustrate  some  nf  ,K    r 

1  cliaphragn,.  Three  contamed^,'  . ,  "  T  "'''''"''''  '^^'^-'h  the 
in  ..o.  ,he  condition  was  stnk  y  .  i,'  J''""  '''^^•'  ">-•— '»tl,orax  ; 
euluT  ,n  the  cavity  of  the  lesser  n.  ^'"^Py^'H'a-     The  pus  may  l,e 

when  perfora.,.,  c'f  the  o!:  r  or  S  oTr.^"'^ V'^  ^'^'""^'^"'^  '"^'  -- 
occurs,  and  the  abscess  is  then  chi  fl.  T''^'  '"■  "^  ''''  duodenun,. 
P'>-g- ;  or  it  „,ay  he  between  ^h^^^T^'''  ^"  ''-"^'  '-'^  "f  the  dia- 
phra,m,  in  which  ens.  ,he  al  sees  ,-  'u  f  °^  "^'-"  ^'''''  '"•"^  'he  dia- 
thouKh  usually  shut  off.     The  .lies    f     ''  "''  ^'""""^  Peritoneum, 

ascending  colon,  or  of  the  appendix  or  fr  """r  .^°"'  '^^"'''■'"■'i"""  "f  il„. 
containing  abscesses  the  mo  t  txouL,^  \'"  '"'"'  "''^""'     '"  "^e  a,,- 

occur  on  either  side,  as  ,n  the  c^se  I  th  T  "7,'  '/  ''« ^orax  u,av 
condition,  reported  by  Dr.  Gardner  t  nf  M  ,       '"^  nttention  to  this 

pneumothorax  extended  as  hig!  as^H  k'T  '  '"  "^''^  'he  signs  of 
which,  ;.../„,,,/,,^^  the  diaphrim  ^  f  .  "^^'  '"terspace,  and  in 
interspace.  ^       *''"    ^'^^  '^"""^  at   the   level   of  the  tl.ir.: 

abscess,  in  consequence  of'the'De!f!!rl-^'''''!T'"'""  "'"  '''"  ''''^■™ntaining 
-"  a  perinephritic  abscess  '  T^  "  ^'-,^^"1°"  ^nd  communication 
phngm  and  produced  a  „|,.       ,.  ,.  ,u        "'    ''     "  ''ad  perforated  the  dia 

In  Cask   irr  .u  '^  -»' 'he  right  base. 

,.,       ^^'''  '"••  ""  the  other  hand,   there   u-,s    .   II      ■ 
kidney,  an  empyema  which  hid  Jrf     !  ,        '  ''^""^"'"S  '"  ^'ry  u>  i„e 

phrenic  abscess  received   it     at  ,71     f     T   "'   =""^"^"^  =he  sub- 
what  unusual.  '  '"'^^'^    ^'•^'"  'his  source,  which  is  so.u.- 

and-on:i::::;::;:^-;:<^-"'c  ab^^s  are  ofd„ubta.letio„,v, 
and  .he^ood^results  whici  'Z:::;'.^:;:^''  """'^"""  ^^^'""^-•'' 

pne«moL;j:  ::;:p;;L; i;;^:,;;^^  ■"  ^';^h  the  diagnosis  ofpyo. 

tollowed  operation.  ^"^^  '^"""«  hfe,  and  in  which  recovery 


^^-^^St-:^---~^^ 


OSLUK:    CASKS    Of'    SUH-PH  l^i;\[C    AMSCESS. 


I     ! 


'■  : 


Case  I.  History  of  dysentery  ;  symptoms  of  ahccss  of  liver :  develop 
ment  <f  a  lar,^e  area  of  tyni/>a>iitic  resonaiiee  in  the  n\'/it  lower  axillan 
region:  diagnosis  of  pro  -  pneiiniotliorax  snl  -  phrenieus  :  operation, 
reeovery.  julin  S.,  ;i,-;ecl  thirty-six.  was  admitted  to  th-  Johns  Ho[)kiiis 
ilosp'tal  on  January  i6tli,  iSyo,  coninlainini;  of  fc-vx-r,  diarrhea,  and  |)ain  ii: 
the  abdomen.  There  was  nothing  of  moment  in  his  faimly  history.  Mr 
iind  typhoid  fever  when  twelve  years  of  age.  He  had  gonorrhea,  but  ni.-, 
sypliih's.  He  has  l)een  a  very  hard  ch-mker  for  very  manv  years,  b, 
September,  iS88,  lie  had  dysentery  ;  not  a  very  severe  atiai  k,  a-  he  ua- 
not  laid  111)  ill  ''ed  ;  !)Ut  the  stools  were  frequent,  and  he  passed  blood  and 
imicus.  He  has  not  been  entirely  free  from  intestinal  trouble  since,  bm 
he  has  been  able  to  keep  at  work  with  but  few  interru|)tions.  Latterly  he 
has  lost  flesh,  and  within  the  past  six  weeks  has  become  very  weak  and 
feverish.     On  several   occasioi^s  the   feet   have  swollen.      He  has   had  n,. 

ehills  ;  has  never  been   jaundieed,  and   has   never  had  severe  pain  in  thf 

region  of  the  liver.      He  stopped  work  two  weeks  ago. 

Condition  on  admission.      Emaciated;   weight    iifi    jiounds ;  aneniu  , 

muscles    flabby;  skin   hot,   dry,   and    salLnv  ;  eonjunctivie  white;  tongiK 

pale,  uidentKl,  and   with  numerous  aphtlious  sores  on   dorsum  and  sides. 

Pulse  96  ;    respiration   30  ;    temp.Tature    IOI^      Langs  are    noruial,  with 

the  exception  of  a  few  dry  creiiitant  rales,    probably  pleuritic,  at    the  right 

Ijase. 

Cardiac  didlness  begins  at  the  f(;urth  rib.      There  is  a  soft  systolic  ap^x 

murmur.     The  .second  soimd  is  reduplicated  at  base. 

Liver.     No  [irominence  in  hepatic  region.     No  tenderness  on  pressure. 

Dullness  begins  in  nipi)le  line  at  fifth  interspace  and  extends  .about  4  cm. 

iulow  the  costal  margin,  15  cm.  in    vertical  extent.     The  edge  cannot  W 

distinctly  made  (Hit,     'I'he  surface  beneath  the  costal  margin  is  not  rough, 

nor  tender.      In  the  median  line,   dullness  extends  3  cm.  below  the  tip  (.i 

ensil'orm  cartilage. 

Si)leen  not  palpable.      Area  of  dullness  not  increased. 

The  abdomen  is  symmetrical,  a  little  full,  t\nipanitic,  nowhere  tender. 

Lxamination  of  blood  negative. 

b'rine.  Specific  gravity  1019  ;  reaction  acid.  Trace  of  albumin.  Xo 
tul)e  casts. 

The  stoils  were  frecpient,  liquid,  and  contained  much  iinicus. 

From  the  history  of  the  case  and  from  the  appearance  of  the  man 
abscess  of  the  liver  vvas  suspected. 

For  the  first  ten  days  in  the  hosiiital  the  i>atient  seemed  better.  The 
numlier  of  stools  in  the  day  reduced.  He  had  no  chills.  On  .several 
occasion^  he  sweated  iieavily  at  night.  'The  temperature  range  was  (Vcm 
98"  to  102°. 


BSCHSS. 

Yfss  of  Ih'cr :  develop 
•  rii^Jit  hnver  axillar\ 
'ireiiieus  :  oper.ilioir . 
>  tin-  Johns  Hopkins 
,  diarrlica,  and  |)ain  in 
s  family  history,  i  1, 
d  gonorrhea,  but  nu; 
ery  many  years,  li, 
•ere  atta(  k,  a-  lie  ua-. 
1  he  passed  blood  and 
lal  trouble  since,  Iiid 
-iptions.  Latterly  he 
•come  very  weak  and 
en.  He  has  had  no 
id  severe  pain  in  t!.e 

I  6  pounds  ;  aneiuit  . 
Ctivaj  white  ;  fon^iit 
)n  dorsum  and  sides. 
i.u;.s  are  normal,  wtli 
Jleuritic,  at    the  ri^ht 

is  a  soft  systolic  apex 

nderness  on  pressure, 
.j-xtends  about  4  cm. 
The  edLje  cannot  be 
margin  is  not  rougii. 
cm.  below  the  tip  !,| 

sed. 

itie,  nowhere  tender. 

ace  of  albunun.     Xo 

uch  mucus. 

)earancc  of  the  man 

ieemed  better.  Tlx 
)  chills.  On  several 
ure  range  was  l"r(iii) 


'■'Sr-'^H:    CASKS 


oi-- 


■'^t'H-PfJKICN'lC 


.AHSCl'S;- 


On  the  2A 
iiLjIit  ren.d   w 


l-th    it   w 


•^^    noted  that   "  i| 


nes 


X 


ion,  i)c>t 


o  didlnes 


'duited  01 


lere    is   ,\\. 


"imaniial 


>^tinri    tend 


lie  lateral  rei 


■s    in   tne  right  Hank.      I, 


iialpatinn.      \() 


erne 


■"''^   111   tne 


.itu 


1  e.xte 


nds  to  th 


"'"  :  in  the  post 


iver  dulln 


•''Pccial  fnll- 


anuary  ,Stli. 


'-■  '"osinl  margin. 


'^■'■lor  a.xdi.irv  li 


•-'ss  IS  not  in 


ne  It   be 


erea.s 


iJi'is  at  the  eighth  rib 


illy 


lie'  tender 


'loiiceableat  th 


ness  on  the  ri>d 


Mpuard. 
diere  was 


1' 


lere  <: 
'(i'-ed 


he 


t:  I'x'remity  of  th 


nght  sid;.  has  i 


!<-'  a  d 


<-'  tenth  r 


isiin 


d'  when 


ncreased,  and 


fn  percuss 


I'L  sense  of  j 


"flween  the  ninth  atu]    Hevenil 


"•"  •■'  ii'nurka.blv  t 


"nnessand  tes) 


pressur 
stance. 


It  is 
e'  is  nia.de 


fuincture,    in    ti 


<-'    teniii 


■i  on   tile  r 


^  ■"p''nitic    j 


o  (lav 


'ercussio 


n  noit 


am 


few  fat 

In  ti; 

iierh; 


f'unt  of  curdy,  thick 


interspace,     p,,st 


sine. 


.\ 


crystals.     The  f, 


pus,  whicl 


'■'■I"|-     a.\i!la;v    1 


'1   (-^'piorator., 


^"  right  flank  tlie  /I 


oilpwing  note  was  d 


"-•ontained  altered 


I"'',    <>b:;iined 


if-tated 


:'ll. 


and 


>1«.  sli.;lit 


th 


■iense   of 


ereiscertainl 


ngers  can 
"leieased 


pnssed  wi 


points  of  the  te 


.V  ;-,'roat  resist; 
nth  and 


ness. 

die  rigiit  sic 


I'Vom  behind  tl 


nice  bel 
^'t-'i'tli   ribs  ;   ]; 


resistance.      With 
ow  costal 


toward  the  kid 


iK'y  with 


''I'linnual  palpu 


lere  is  d 


Lie   ther 


is  no  dist 


and 
inct  tender 


i^'inct  finln 


nitercostal  spac 


es  are  1: 


'"'irgm,  and  especial!) 

"so  marked  t 

ra-scapn|;u-reg 


ion 


e   IS   al 


)elow 


L'ss  i;i  theitil 


eiiiier 


iiiid-ste 


ness  m 


riial  hue, 


riglit  luiiiba 


extends  ti 


r  s 


lower  tiiargm  of  ih 


iree  liner, 


L're  not  so  we 
pace  be)-ond.      1 


1'  marked.      Th 


loll  on 


e  hfth  to 


eis   hrca 


CO.'- 


pulmo.'iary  note  to  1 


•'^tal  border.      \ 


dth  (5 


iver  dull 


ere 
ness  in 


5  cm. 


'"  "ipp'elin.',  fr 


breadth  on  the  .•- 
I'.vieiidi 


<'>ver  nvu-gin  of 


seventh  r 


sixth.      'I 


'1   mid  a.xillary  hnc    tl 


"),  and. 


ng  Irom  exactly  th 


oe.ow,  the  most 


lere  is  didin 


ess  f)r 


oni 
lere  is  a 
I  linger's 


where  it  passe 
However,   to  be 


riorlv,  th 


s  on   insen 


e  -seventh  inters 


alhc  tvi 


Sll) 


'y 


y,  tne  metal  Ik 


.Vnte 

'iehiiul.  It  extends  to   [ 


slightly    dull 


into  bowel   t 


e.xtrenie  met 
pace  to  upp,,,-  margin  of  el 


npaiM, 


ynipanw 


note 


tyn 


jf( 


■Pii 


eve 


dl 


'tn. 


ere 


leloie    bowel 


'Pany  extends   i 


PiissKiii  m  a.xidarv  1 


H'sterior  axillri 


o   within 


'ympain-  is 


>'Oes  appear, 


reachec 


4   cm 


line. 


Vlloiiet 


ine  is 


ler,  tympanitic  ar 


distinctly  llati 


\\, 


inc. 


Ill  ;i  line  drawi 


ea  oeciioi 


er,  and    ih 


len   iiiriied 


1  at  th 


pl'ienic  air-comaininir  ;,i 


e  level  of 


totl 


le  surgical  depart 


On  tl) 


K  abscess 
inent. 


d'es  p(;silioii  of 
ensiform  cirtil; 
^•'is  nia.Ie,  and  ti 


eie   IS  niova 


seventh  to  t 


iL'e. 


.\ 


nipple  1 

'n  side,  prr- 

>'i  '  dulint-s--. 

'•nth  interspace 


•nagiicMs  of 


;i  SI, 


le  patient   was   traiisl, 


e  29th  Dr.    ]{. 


;^'iitb  111)  in  the  mid 


istei. 


a.xilli 


resected  al)oa 


,^'iiiiitoiis  pui,  which  had 


ry  li 


"c,  and  rem 


I'^^'l-aiient  rallied  well  from  tl 


111  acid  react! 


t  an 
oved 


UK 


''  'iml   ■!    half  of 


rred 


tiic 


■eiiruary  2nd.     T 
iiperature.      His 


le  operation. 


on,  aiul  very  di 


i''"iit    a  litre  of  a  thick 


liinct  odor  of 


ut'  iei 


itic  note  is  ev 


le  last  f 
general 


eW    (l; 


lys  til 


.imphoric 


en  more  im 


conditi 


^■patient  has  had  a  shght.k 


on,  iiowev 


vonnt. 


ation 


en 


in  cnaracter.      h  c^t, 


-se  than  before  tlu 


er.  is 


.J. 


ends   ant 


en  ir 


ly 


operation,  and 
as    fa 


■e  lympan- 
"  is  almost 


r  as  the  nipple 


liii(.'. 


"  osi.i:k:  casms  oi    sri!-i'HKHNic  abschss. 

where  it  is  only  lo  (  ni.  from  the  nipple  line.  'The  area  is  triangular  in  sha()c 
tile  iipex  beini;  toward  the  sterninn.  It  is  15  cm.  in  transverse  diameter 
Tile  liver  seems  pushed  far  over  into  the  left  h)  pochondruuii. 

lotli.  Simx'  the  last  note  the  p.itient's  condition  has  rapidly  imijroved. 
The  temperature  has  been  but  sli;,ditly  above  normal,  the  sweats  have 
stopped,  the  diarrhea  checked,  and  his  apjietite  has  become  very  gucd 
I'he  wound  is  dressed  every  day  and  the  cavity  irrigated.  Dr.  HaKtti.ii 
is  now  able  to  [)ass  his  finger  far  down  into  the  flank,  reaching  quite  to  th, 
level  of  the  crest  of  the  ilium.  .-\  Hat  tympany  e.\tends  in  the  mid  axillarv 
line  from  the  lower  margin  of  the  eighth  to  the  iliac  crest. 

14th.  (ieneral  condition  remains  excellent.  'I'he  cavity  hasreduccil 
very  < onsideialily  and  the  discharge  has  lessened. 

The  improvement  continued,  and  the  patient  was  disc'iarged  well 

C,\\sii  II.  Tiilicrcuh'Hs  pyelo-iu-phritii ;  tuberculous  colitis;  perj\n:i 
tio/i  at  splenic  flc.xu'c  of  colon,  7i'ith  the  formation  of  a  peri  nephritic  air 
eoutainin,!^  abscess  ;  prominent  tumor  over  tenth,  eleventh,  and  (ioetf/!i 
ri/>s  />ehinJ ;  incision  an  J  drainage ;  pulmonary  taberculosis  ;  deatit . 
autot^sy.  In  October,  1887,  I  saw,  with  Dr.  R.  H.  Harte,  of  Philadelphi;i, 
a  else  which  illustrates  a  somewhat  unusual  form  of  this  condition.  IT- 
was  a  young  man,  aged  about  thirty,  who,  as  early  as  1880,  had  pa^.scii 
blooil  and  clots  with  the  urine,  and  was  sent  to  California  under  the 
iiiip:es>ion  that  iie  had  liright's  disease.  He  lived  a  [iretty  hard  life,  and 
h.id  been  treated  for  stricture  (jf  the  urethra  and  ii.-itable  bladder.  WIkt. 
Dr.  Harte  saw  him  in  July  he  had  lost  much  flesh,  was  very  pale,  but  was 
still  fairly  muscular.  The  urine  contained  pus  and  blood  ;  the  bladder  wa.^ 
\''r\-  irritbale,  and  micturition  was  very  frecjuent. 

Ivarly  in  September  he  had  chills,  which  were  supposed  to  be  malarial ; 
widi  th.ese  the  fever  was  high,  and  he  sweated  heavily.  In  the  middle  01 
Octob;  r  diarrhea  of  an  obstinate  character  set  in.  When  I  saw  him  hf 
w.is  pale,  somewhat  emaciated,  with  an  irregular  fever  and  occasiotiai 
cliiils,  which  were  evidently  of  a  septic  nature.  He  had  profuse  diarrhea, 
aiid  the  stools,  at  times,  contained  bmall  quantities  of  pus.  The  urine  was 
\eiv  lujruhnt.  On  examination  of  the  abdomen  nothing  of  special  note 
uMs  observed,  liehmd,  on  the  left  s'de,  beneath  the  skin  over  tenth, 
elevemh,  and  twelfth  ribs,  there  was  a  prominent  tumor,  somewhat  hcnii- 
s[)herical  in  outline,  an  1  nearly  ecjual  in  extent  to  the  palm  of  the  hand. 
It  was  soft,  not  specially  tender,  and,  on  percussion,  when  he  was  in  an  erect 
pasture  or  on  his  belly,  gave  a  most  remarkable  tympanitic  note.  On  the 
other  hand,  when  he  was  on  his  left  side  or  back  the  note  was  dull.  On 
coughing  there  wa^  a  distinct  impulse  in  the  tumor.  .Antei mrly,  there  wa> 
nothing  to  be  fell  on  deep  pressure,  but  there  was  evident  thickenin-  and 
pain  in  the  left  lumbar  region.     It  was  thought  at  first  that  this  (irojection 


"^aVtAi^Mtei^aJ 


liSCHSS. 


OSLHR 


CASKS    OK   Stra.pHKKNlc    ABSCKSS. 


■ident  thii'kenini'  nm! 
it  tliiit  this  [irdjeciion 


™«~i^;:r;;;:LX-  • 

fr-^ely  the  a',....     There  was  ev  JJ  '  '"'  '''■   ^'^"'^^^  '^'^  "P- 

co.n^u„,cat.ci  with  the  colon  at  the  splenic  7"'""',""™""^'"'  ■''    '-<^ 
«  "ch  would  adnm  a  lead  penril       ,-  ,e  "  T  """'^^''  '^'^   "P^"'"" 

I--gm  and  produced  pleurisy  at  the  ri  ht  b  "e''\  ,''  '"'""'"^  ""^    ^i'- 
P-^rcss,n,  tubercular  disease  of  tl^  ^n     '         ^'"  "'^  ^^'^'^^'^^  -^^ 
-;ecl  a   „un.ber    of    small    tui    r  ulo^      J"''      ""  ^'"''    ^''^-^  pre- 
='-^  ened  and  contracted.  ^eZed    ub      "T""     '""'    '"'-'''-  '- 

■in  abscess  of  the  prosta.  .^,^;  '"^^^1  '"''erculous  ulcers.     There   wis 

were  thickened  and  ulceu.uct    '      ^  '"'^  "'^'  ^^''''''^-•-     ''''k-  ureter's 

J'^econdition  has  been  met  with  foil      •        •   • 
-e,  which    was    trans/erred  \o    n  J  ^^I?  '"^7'  ^  '"  ''-    "ollow.n, 
Un.versuy  Hospital,  Philadelphia  "    '^"'  ''^'S^'^'^  ^'^e  at    the 

Case  III.     Injury  to  am,  a,>d  hnrh  ■  1,        .     ■ 

asthenia:  death  ;  autopsy.  '~'^^'^"'o^'o,  0/ fetid  pus;  septic  fever ; 

^^^^^^^^^^^  to_  the  surgical  wards 

wheels  of  an  engine.     The  left  an„  ua    cr' ',/.''    ."""  '"'"^  ""^^'•-  '^e 
-""d.     The  arm  was  amputated  at  ih    ^^^  '^  '^^  ^  ^-P -alp 
''  '-""cl  he   complained  of  a    n„„  ' .    ■  "^^     ^''''  ""  ^^^^  he  had 


^--■Wa,  and  he  con^plam;;?      ^    ^^ ''it     ^^"^  ^  ^^^  ^^  '^^ 
-yMpelas   developed    in  both  arn,\n    f  '  /''^  "'"''■     Subsequently 

■Kimrssion  signs  of  inflammation  applardrtl   "'    r"    '""'^    ""''^'^•■^   ''^^•" 
mdicated  by  a  rise  of  temperature   IT  ''^'  '"fra-scapular  region 

an.  h.  was  transferred  to^he^m  ^^^  ::j  ^'!;!,  ^^'^'^.  ^'^wing  breathir;  ! 
■>ln|a.st  healed.  E.xamination  of  t  J  ^^  ^ '^  ^'"-P '^'^  this  time  had 
dullness  at  the    left    base,  extendinrnea  L  asT  '    --"--n-bed 

-apula    and,  laterally,    to    the  mid-ax  h'     V    "  ''  ^'^  ''^"^^'^-   "^^  ^^e 
.^'™"^l-d;on    auscultation,    fee  t       il ? •  ''""      ^'^^^''^    ^-'"'tus   was 
;;'P'"'-n,    rales.     Slight    coug        v'er        ^      "^''"^''  ^"''  «"    ^-P 
'^risy  was  suspected.     Tbo  condition  r  ""T"'"' '''''''■      '^     ^^P^ic 

f^^  several  weeks,  during    which  there    w^:    '"       r'"'"''"^  ""^•'^'^"g^-'d 
-"•P'a.ned  at    times  of  pain  in    the  ilia7     "''    "  ^^'^^''^    ^^^^^     He 

'"'  '•'^^''""  ^'^d  left  side,  particu- 


8 


()S[.i;k  :  c.v:es  or  sui-.-itiki-mc  ahsckss. 


I 


larlv   when   he  I'lew  a    deep  lirealh.      Ho  soon    began   to  -pit    up  f.  tiM 
[)iis,  and   in   iw    ty-fonr  hours   brought   up  several  ouncps.      It  was    con  . 
chided  thai  a  locahzcd  empyema  had  perf-irated  the  km;,'.     C)n  exann 
nation,    tympanitic  resonance,    amplioric     brealhinj,    and    me'allic    ral<-. 
were  found   low  down   in  the  po-,tero-hueral   region,  beneath   the  eighdi, 
ninth,  and  tenth  ribs,  indicating  ])neununhora.\. 

The  autopsy  s!)Owed  the  existence  of  a  large  abscess  behind  th( 
left  kidney  and  descending  colon,  extending  from  the  diaphragm  to  ilu: 
crest  of  the  ilium,  'i'he  chief  part  of  the  abscess  lay  above  the  kidney 
and  beneath  the  diaphragm,  and  in  this  region  there  was  a  distinct 
cavity,  partially  occupied  by  dirty-brown  pus,  similar  to  that  which  ibr 
patient  had  expectorated  during  the  last  two  days  of  iiis  life.  Part  ot 
the  diaphragai  -as  in  a  sloughy  condition,  and  two  orifices,  through 
earh  of  which  the  point  of  the  index  finger  could  be  passed,  comnuiii-:- 
cated  directly  with  an  abs^css  cavity  in  the  lower  lolie  of  the  left  lui)-. 
■j'he  pleural  membrane  of  this  part  was  greatly  thickened,  and  there  wa^ 
a  small  localized  empyema  betwsen  the  layers.  There  were  areas  of 
recent  broncho-pneumoiiia  throughout  the  other  lolje.  The  left  kidney 
was  small,  and  presented  at  its  upper  part  a  distinct  cicatrix,  to  which 
the  capsule  and  adjacent  tissues  were  strongly  adherent. 

The  sequence  of  events  in  this  case  was,  probably,  as  follows  :  Wound 
of  kidney  with  bruising  of  tissue  in  lumbar  region;  sub-phrenic  abscess; 
localized  empyema,  probal)ly  from  contiguity  with  sub-phrenic  abscess: 
perforation  of  diai)hragm  and  lung,  with  discharge  of  pus;  developmetu  of 
a  sub-phrenic  air-containing  cavity  which  gave,  in  the  lower  and  lateral 
aspects  of  the  left  side,  the  signs  of  pneumothorax. 

I  regarded  this  case,  when  admitted  to  my  wards,  as  one  of  sei>tic 
pleurisy,  passing  on  to  empyema  and  perforation  of  the  lung.  The  physical 
signs  of  ]ineumothorax  were  of  the  most  characteristic  kind,  and  I  must 
ccifess  that  it  never  once  occurred  to  me  that  the  air-containing  cavity  was 
below,  not  above,  the  diaphragm. 

C,".\sK  4.  Ac/f/e  ilhicss ;  si[i^>/s  of  empyema;  operation;  pleura  J  ra . 
evacuation  of  lar^e  sn/)-/>hrenic  a/>ucss.  John  M.,  aged  twenty-four,  lirt:- 
man,  admitted  April  30th,  1892,  complaining  of  pain  in  the  right  side  cv 
the  chest.  Nothing  of  any  note  in  the  family  history.  The  i)atient  had 
measles  when  young;  otherwise  has  been  remarkably  healthy.  Denies 
excess  in  alcohol  :  admits  gonorrhea,  but  has  never  had  sy[)hilis.  His 
bowels  have  been  regular;  he  has  had  no  abdominal  pains.  The  present 
illness  began  about  a  week  ago,  with  headache,  loss  of  appetite,  lie  kept 
at  work  until  two  days  ago,  when  the  pain  became  very  severe  in  the  rmhi 


side  of  the  thorax,   and  was  much 


iraviited  bv   coughing  and  during  a 


deep  breath.     He  is  positive  that  there  wa 


s  no  chill,  but  he  has  had  one 


B. 


^^fClii^li^MiSti^iSs^^^ 


OS!.Uli 


CASKS    OF    Srn.PHKKMc    AHSCKSS. 


or  two  heavy  sivonts       I'       i 

'■-  '-^  ^-  fiv;.;,e„  loin'SM:;;  ir"':  '^^^  "^^"  '--•  -"  ^^^ 

'•^'";'    7"-   '■•«-',„„.   the  left   Sid.'     r"^;"'\'''^^^'^^'"'^"-'-"".-dl.no„r. 

-/---'- o::r;::-^^^         on  the...... 

«'  'I-   "Pf^er   border  of  the   st.th  '    n  ''  ''      '""  "^^'^'  ^  '-^"- 

resotunce.s   defective  at   the  ri-ht  '"' '»'""'-T   line      Behind,  the 

-^  P'-Jbly  there  the  hne  of  ^wt^    ;""   T       "   '""'^^^  ^^"'-■>-  ^  '"^ 
^--      '-he  frenm.s  is  dn.,nishedX",e  I  "'''"  ^'^''^'^'  "•'"'  ^'^  '-- 
Auscultation  is  ev  -      i  ''"''-''''• 

'-ntshedin  intensity,  and  i^  ,L  ^ -eT'"^"^'  ''""  '^'^'^^  ^^^'^  ' '- 
'^^V  -les      Ti,e  condition  of  the  l^a^  tn      "T^"   "^""  ^'^'^^'^  ^^  ^  <-. 

I  he  abdomen  is  full  ■  the  '"''''■ 

"0  glandular  enlargemen;,  and  Th^'  '"""     '""'-^   ^^^  ""  tenderness 
d;.^tn,ct  increase  in  the  si.,  of  th    'l    '  T'  1  ''"''''   ■""-■"t  w.s  thj 
'  t  at  the  costal  n.ar,in.     Tk't^^^Z^^  1'^  °'  '"''"'  ^^^"^  '^  -^i' 
P'-^-d'-     There  was  marked  leucor    osif  "'T  "  '''''''  '""^  -'^'-'•■" 

''°"'~^^'°°°  ^^hite  corpuscles  per 
The  urine  [)resented  a  trace  of  niK      • 
specific  gravity  1020.  ^"'"'"'  ^^-'^-'^  ^^^'^^  nmber-colore,!,  acid  • 

The  patient  had  a  sli.rht  coujrh      ■  i 
expectoration,  in  which  there  .ere    nil !  '  "^"™-P"^"'^"t.  ^li«iuly  bloody 
'-- evident  durin,  the  first  wcSc  h ^thrr  "'r^^"  encaps,=  latec[ 
^■^'^■^'  .'"■    ,E-ry  day  the   ten.penu  r     ^,  'iT     ''''   ''"'  '"^'-'^  «- 
occ..s,onally   reaching    ,05^   ad   o  c,'   10  '      T^'"""'^    '°^°  '''"<'    -4°. 
■-  to  r.o.      He  had  at  ti,„es  hea  y  swe.ts        /'  '''''  ""«^^  ^^^   ^^'-n 
;d  two  severe   cl,ills,  in   one  of    i;  ^2' "'^'  °"  "^  -^   of  May  he 
'h;-^"  nessat  the  right  ba^e  persis    d  ■       ''""'""^   ^'"^'   ^"    '°6..^ 

"'""'  ^'''-  •-•"d  in  front  in  the  r.cu    hi  .'      """"-  '"  ''^^^  ^^^^^  ^^''""t  the 
-"-d  very  little  doubt   to,)r    n"  '"'   T""''  '' ''' '^^'^^^   -^-     Th  re 
-t  .here  was  pus  i„  the  p^^""^^'"'''.^'^^^^-^^   the  case  ca^" 
'r""^-"  "'^tainin,  any  pus  "  "^'^"'^"■"^'  "^^le  was  inserted 

""""«   I  he   second    week    th 
;;-i^ted  until   May  the  8th,  ar^d   then'lirr'"'''    ''''''''' '  '''   '^ver 
between  <;;»  and  99=.     -phe  sok  en  °  "°'''"^'''  ^1^^  ^ange  beins, 

-t,  hut  he  seeded  aK^:        'Ur^^n    '^f  ^  '"^^^   ^-^'^^'^- 
^^°-^adu„nuuioninthe,nn.berof    ucoc^;;      "  ^^''  ^'- blood  count 

^^"~ '3,000  per  c.cm.     The 


lO 


0SLF:K  :    CASES   OF   SUB-PHKIiNIC    ABSCESS. 


temperature  remained  low,  and  patient  seemed  to  be  soinewliat  better  until 
the  151)1,  when  it  rose  to  nearly  105°,  and  the  pain  in  the  side  iiad  l)ceii. 
worse  ever  since  he  sat  up  with  the  bed-rest  two  days  a>;o.  Yesterday  it 
Ijccanie  very  intense.  The  physical  signs  have  scarcely  changed.  There 
is  still  flatness  from  the  fourth  rib,  and  behind  from  just  below  the  angle 
uf  the  scapula.  The  apex  beat  of  the  heart  can  now  be  accurately  localized, 
and  is  in  the  fourth  interspace  1.5  cm.  outside  the  nipple.  'I'he  respiratory 
sounds  are  feeble  and  dist.int. 

On  the  i6th  the  patient  was  agnin  aspirated,  and  this  time  pus  was 
found  which  was  a  little  stained,  and  contained  the  staphylococci  and 
micrococcus  tetragenus.  Shortly  after  the  aspiration  the  patient  was  seized 
with  a  tit  of  coughing  and  began  to  expectorate  a  quantity  of  reddisli- 
brown,  anchovysauolike  sputa,  which  was  examined  for  ameba,  without 
finding  any.  It  was  then  determined  to  transfer  to  the  surgical  side  lor 
operation.  Before  the  transfer  the  following  careful  note  was  made; 
"  The  patient  is  propped  up  in  bed  ;  the  right  side  of  the  chest  seems  a 
trifle  fuller  than  the  left,  the  upper  part  looking  more  nearly  equal. 
Motion  is  defective  in  the  lower  right  front.  On  the  riglit  side  flatness 
begins  in  the  upper  sternal  line  in  the  third  space,  at  the  upper  border  of 
the  fourth  in  the  nipple  line,  and  at  the  fourth  space  in  the  mid-axillary 
line.  Posteriorly,  flatness  begins  at  the  angle  of  the  scapula.  In  the  erect 
posture  the  upper  limit  of  dullness  in  front  appears  to  move  slightly.  On 
the  right  side  the  percussion  is  clear.  Respirations  are  clear  at  the  apex 
in  front,  but  diminish  greatly  in  intensity  over  the  flat  areas,  and  is  of  a 
distant  tubular  character.  The  voice  sounds  have  a  somewhat  nasal 
quality.  The  vocal  fremitus  is  only  just  perceiitible.  In  the  infra-scapular 
regions  the  inspiration  has  a  more  distinctly  tubular  character,  and  there 
is  very  distinct  egophony.  The  liver  does  not  appear  enlarged  downward, 
and  the  border  is  not  palpable." 

The  case  was  thought  to  be  probably  empyema,  though  the  possibility 
of  an  hepatic  or  subphrenic  abscess  had  been  considered. 

The  following  is   an  abstrnet  of  the  report  on  the  operation  by  Ur. 

Halsted  : 

The  eighth  rib  on  the  right  side  was  exposed  by  an  incision  from  the 
axillary  line  to  the  nipple  line  ;  a  portion  of  the  rib,  5  cm.  in  length,  was 
excised.  It  was  found  that  the  costal  and  diaphragmatic  pleural  surfaces 
were  adherent.  An  incision  made  through  these  and  the  diaphragm 
opened  at  once  into  a  large  sub-phrenic  abscess,  which  was  freely  evacu- 
ated and  packed  with  iodoform  gauze.  The  patient  reacted  well  from  the 
operation,  and  made  practically  an  uneventful  recovery.  The  discharge 
of  pus  gradually  diminished,  and  he  had  fcver  only  on  two  days.  He  had 
a  chill  on  the  30th  of  May,  and  on  the  3rd  of  June,  atler  which  he  had  no 


■B», 


fiinher  rcvcr.      ijjs  wci'mIii 

rh^U^^d  August  ,5th  n'uh  oil^y  JZ.ul!"   '^'  ''"""''''  ''"''  ''^'  ^^'^^  <1- 

'-' August  3,,,,  ..S,a,complai„in./r,.:     '  T     ''*'  -'^°""-y.   adnm- 

d:phthena  t.vi,:.,  but  l.as  b...;,.  unt^l  L't  >  "^  m  '"^^''^'^■'^  ^"-'  ''"'^' 
F--;  -lincss  began  ,!„•,,  „  •„,,  X",  ^'^''^-''-'^'^^  -'<!  -trong.  The 
;c  ankles  and  kne.s,  and  s„bse^,;^^,  'f  '""  T'"  "^■^'""«'  ^^  «-^  '" 
'-dentb,  fron.his  account,   he       d     '      "/'^^  '^'"^  --'   ""-r  joints. 

^-ted  attack  of  acute  W.euuKUisn,.      He'  •''"'"  '■'"^'   — vhat  p,o- 

very  well  until  tsvo  weeks  -.vn,  ,,u  ,„  ,7  '"""  ™"vales..ent  and  doin,. 
-cl  slight  expectoration.  Fo  ^  J"  '"'  "^'7  '"  ^'-  ^^'u  side.  couglC 
-s  of  breath,  .hich  lately  ^^^'  "^^^ '- '-^  '-d  son.e  short: 
'  a-rhca;  the  bowels  have  bee  "  ' "  ,,  "''  ""'^'-  '^^'  '^  ''''^  - 
'h'l'v  <cehngs^  but  no  definite  rigor^  ";  '  'V^'^"^!"^"  '^^  "e  has  had 
--^-1   freely  at   night.      ,Te   ^:  Z  t'^^^^"  ^^^-h-  --^  '-s 

pounds  suice  the  beginning  of  his  ,i-vs  "'    "''  "''°"'  '^^'^■"ty-five 

On  admi.ssion  the  paiient  was      "  ' '' 
■f^  '^4,  regular  ;  the  ten^per^ture  'l'^^""    '"''',  ^'■"^'""'  "^  '"  ^ed,  the 
I  lie  respirations  were  28.  '  ''""  "■'^'""  "^  '"'-'^v  hours  to  ,03°. 

T'lorax.     JVominent  on  the  ri  -hr    i  >        ■  ■ 
»•"  -I'  "«  'lie  left,  and  there  i,  distinct  l",'  ''"''  ""*  "^°^-'--  "^'''^'•ly  so 

spaces  under  the  nipple.  '  ^^^'^'"^'^  '"  ''^'^  fourth  and  fifth  right 

Percussion  on  the  riwht  .sid  ■    ■ 
^he  infra-clavicuiar  space,  g^uluX'sln  "'"'"'"'  '^^"^P^"'^'^  '-e^onance  in 
'-  1'-  or  dullness  extending    ^^  t7\  '"''  ''^""^^  ^'  ^'^  '"""h  rib. 
i-Uhove  the  angle  of  the  .scan  -f      l  'T  "''''''  "S''™  '"  ^  Po^n^ 
■^'«'ilute  flatness  in  front  is  clistinalvhi-W  %"'"''  ^'"''''''  ^''^'  '■"-'-'■ 

-flat  regions.     The  respirato         >    S"'      '  ^'''^ '^-i'- is  absent  in 
•!'-e  parts,  where  the  ,e.pH-ato,^   Z  ''"'"''"^  ^'^''^  ^^^^P^  ^^ 

'^\;f  the  physical  exan,!natio;  is:  ^  Xe'^  """'^  =^"^'"''^-     °»  ^^- 
,      i'ere  .s  no  expectoration.     The  .Z   i        ■ 

y^  ''-^-  The  first  s.nM  is  louj^J  ,  "^  ^""'^^•-  ^''^  ^^'^  nb  in 
"-  --^in  of  the  sternum  was  l>^a^L'7'  7'  '"  '''''"'  '  '^'^^  - 
«'^^  a  suggestion  of  a  thr.ll  ,u  ,h..  !  ,  !'"  "^''^  'f  ^-  ^n  palpation  there 
^"  d-tole,  but  no  definite  nn^i^  ^?^^'  ^f  ^'^^  -^  ^  ^^.h*  echo 
jca   on  inspection  :  the  liver  dullnes".^     '"'""'    ^"^"^^^    ""'^'" 


Ijelow  the  costal 
'lie  coiuraction  of 


inarym. 


•J' 


lie  b,.rl 


extend 


jwlpable.     The 


the  altdom 


er  !s 


!s  three  fi 


patient  rem  lined 


not  accurate 
iiial   muscles.     The  ed. 


'"  the  medical 


".i(ers  breadth 
ly  palpable,  owing  to 
e  of  the  spleen  is  not 
vards  for  five  day.s.     The 


ll- 


I  ■ 

If 


ii 


12  oslkk:  casi:s  or  sub-phrenic  abscicss. 

temperature  ran^e  was  from  yS'  to  lo^s'-  He  liad  no  chills,  sonu 
sweating;  tlie  pulse  ranged  from  no  to  130.  On  the  7th,  pus  was  drawii 
off  with  an  asjjirating  needle,  and  the  patient  was  transferred  to  tlie  siir 
gical  side  .villi  the  diagnosis  of  emi)yenia.  'I'he  pus  was  creamy-looking, 
but  no  micro-organisms  were  found. 

An  operation  was  performed  by  Dr.  Finney  on  August  iit'  .  About  y 
cm.  of  the  ninth  rib  on  the  right  side  was  excised.  .Xn  aspirator  needle 
was  then  parsed  through  the  tiiickened  iileiua,  but  seemed  to  enter  a  soliij 
mass,  and  nothing  was  obtained.  On  a  second  attempt,  250  c.c.  of  pus 
■were  withdrawn.  Tlie  pleura  was  then  incised  just  above  the  diaphragm. 
No  pus  was  found,  but  100  c.c.  of  clear  serum.  The  diaphragm  presented 
at  the  wound.  The  pleural  cavity  was  shut  off  as  completely  as  possible 
with  strips  of  gauze,  and  the  diaphragm  was  incised  with  the  Paciueiiii 
knife,  opening  into  a  large  pus  cavity  with  ninnerous  pockets.  About  100 
c.c.  of  pus  wore  evacuated.  .\  rubber  drainage  tube  was  inserted  into  the 
cavity.  The  [)atient  did  remarkably  well,  and  the  teuijierature  fell.  He 
was  dressed  daily  ;  the  discharge  was  free,  and  he  gained  in  weight,  and 
left  the  hospital  on  September  yth,  still  with  a  slight  sinus. 


-V. 


AP.SCIISS. 

le  had  tiij  chiils,  sonir 
1  the  ytli,  pus  wasdrawji 
s  transferred  to  tlie  sur 
pas  was  crcainy-lookirij:, 

I  Aui;ust  nt'..  About  9 
_d.  An  asjtiratnr  iK-cdlr 
t  solmikmI  to  fntcr  a  soli'i 
attempt,  250  c.c.  of  [)iis 
.1st  above  the  diaphragm. 
rhe  diaphragm  presented 
IS  completely  as  possible 
ciscd  with  the  Faiiuuiin 
)iis  pockets.  AbcKit  100 
jl)c  was  inserted  into  the 
le  teMi])erature  fell,  He 
e  gained  in  weight,  and 
;ht  sinus. 


hjS^^i.r'^  ■ 


■m 


^  ""^x  m 


^''■<H.  M|.;i,.  s,„.,K,v. 

I  mi. 


TUHPiRCLLOUS    l-LKL'RISV 


III.   (Jk 

'V^-    l)l\(i.\()B|.s 


liV 


>'r..t.'ss,„- „r  .v,..|,Vi„,,  .,„|„„  „   ,,,    'V   ■^'•''■' 


'"^"'■'"""""'■'' ■--•"-"^-'-^.-M....  ..,..,, 


IJ  ()  S  T  O  N 
PRESS  OF  DAVID  CLAPP  &   sON. 

1898. 


TUIJRRCrJLOlJS  PLKLTUfSY. 

Mr.  PltKS.DKNT  AND  FrlUWS  •— 
'"Hi  Without  mnkin.r  i„vi,|i,.,,,  ,.,,..      "*'^""  /'"'  |>le.i.i8y; 

>i-or„„e.pe;:.::^:  'z-:r'i:r;^^'''•'"--: 
r«;  In  the  poi,t-mortem  room  ~\  t,,.  *         . 

"r.i,c  i„oi,ie„ce  of  t'^>,^r.,.iZ^~;i  :T;:r,  rT 
«..;.e^e..,e,eve,,,w.a.,:i:;rj;:t;::;",,:!;-^"''"-'> 

Accoraino'Iv.    with   fl.^   i  ■    i        •  '^^' 

V  " -^  ^''®   ''^'"'J  ass  stance   of    F).-     p 

I  i.«v„  „,„.rf„,i,.  ,„„,y,5j  ,1,^  „„,,..L„<„„;  ':„,';.   '■   ■ 

«.cce,„v„  ca.e,  ,V„,„  ,„y  „,„„,,  ,,  „,,.„ „,Xlfil     " 


THE    SHATTUCK    LECTUUE. 


1  I 


tlu;  record  is  of  intcro.-it  as  showing  the  incidence  of  tuber- 
culous pleurisy  in  u  medical  service  varying  Ironi  70  to  !)U 
beds.  OF  the  101  cases,  there  were  o2  in  which  the  pleurisy 
wiis  definitely  tuberculous.  I  liave  estimated  as  such  only 
those  in  which  tidx'icles  were  j)resent  on  the  j)leural  layers, 
either  as  fresh  miliary  granulations,  eascous  masses,  or 
diffuse  fibro-tuherculous  membranes.  Of  these  cases  there 
were  eight  with  piuulent  exudate,  all  associated  with  pneu- 
mothorax, a:id  two  with  luomorrhagic  fluid.  Seven  were 
cases  of  acute  miliary  tuberculosis  with  fibrinous  and  sero- 
fibrinous exudate ;  four  were  instances  of  acute  miliary 
tuberculosis  with  a  i)urcly  fibrinous  effusion  ;  and  thirteen 
were  cases  of  chronic  sero-fibrinous  exudate  with  more  or 
less  thickening  of  the  i)leural  layers.  In  four  instances  tiie 
sero-librinous  exudate  was  encapsulated. 

There  were  thirteen  cases  of  pulmonary  tuberculosis  in 
which  pleurisy  was  present  without  our  being  able  to  say 
definitely  that  it  was  of  a  tul)e;-culous  nature.  In  ten  of 
these  eases  the  exudate  was  fibrinous,  and  three  sero-fibrin- 
ous. It  will  thus  be  scan  that  the  incidence  of  tuberculous 
pleurisy  among  these  lUl  cases  was  a  little  less  than  32 '/f , 
By  far  the  most  common  forms  of  pleurisy  arc  tiie  sero- 
fibrinous and  fibrinous  secondary  to  acute  disease  of  the 
lungs,  orocciu'ring  as  a  terminal  process  in  chronic  aflectioiis 
of  the  heart,  arteries,  or  kidneys. 

{/))  In  the  ivards. — Passing  now  from  the  certain  and 
definite  data  of  the  ])ost-nu)rtem  room  let  us  turn  to  the 
wards  iind  in((uire  into  the  etiology  of  the  cases  of  acule 
pleurisy  whicii  iiave  been  unde  observation.  I  have  thought 
it  better  to  review  only  tiiose  cases  in  which  there  has  been 
a  pleurisy  with  efi'usion  coming  on  acutely  or  sub-acuteK', 
and  in  which  the  pfFusion  was  sero-fibrinous,  not  simply 
fibrinous  and  not  purulent.  I  have  excluded  the  ibrnior 
from  analyt'  because  of  tiic  very  great  frequency,  as  the 
post-mortem  reports  siiow,  of  ii  simple  fibrinous  pleurisy  in 


TOBK,.cl,OL:s   IXKUHISY. 


'•'  '"»'<^  definite   ,.,„d   nvll    '  r  ^''''"''''  "«  "-'.v  have 

^'-n  the  n.ct  U..  ahj       ;  "  ;r;r''  "'"'"^>-'   -"  V-utly 

-•«  -■'''-•  .d.nine.l  direc.lv  ?  ^^  ^"^'""'  '""'  """  "-^e. 
'>ver  at  once.  Thi.  nru-  ■,;  "'"  .■""'^'"'■■''  ^^'"''^  '"•  tmncd 
^'^'-•^-nceorp::  „  :':^':^^'^^•'--l.aU..na,.k- 
pne.in.uthurax.     Still   h  .  '   1','  "'''""'^    '""'  ^'''-'  '"^^fanee.s  of 

'"""Wins  »ualv6i,s,    i|,„,    ,,,,„  ,  'V       ''">  "»««  ill   li.e 

"■'■"'  '"■"  '""'-I    «-    if      1  "'"*"»'  "•  "'^'   -"* 

-^--■^Mvei-ea,;;,  2;;;f  *»'"•     Of  ,l,e 

'•'«  ;  -1«  ill  llic  „.|,it„  "  •  '"  """  "1  llie  colored 

™''''»'"S:f:::;:;r':"f-'«"'-i»*.iie.ii,.,.. 

»iiisi,lore,l ,  '""  ">'  ""■'  '""""-ilia  ,,„i„„  ,,,  ,„  ,,„ 

l^'iist :   mode  of  onso^       T 
'^f-y -n.ent,  .ineeU  nui  i::'r' l^r^-'^  '---^^^ 

^''''^''^-'-ide,o.lJ::i;^;:;;;-";'-.p%witha 

->;et  .«  .no.e  co,nn,on,  h„t  hv  no  n.e-,  ."s  el  ■  '"^^''''""^^ 

It  IS  8„  <liffie;„)t  f„  ,  ,  .„;     ,;    "o '»ean.  cha.aetei-isti,.. 

!''-«  ve...  n.ueh  .vlianoe  u  on  i  r"'"'  """  ^"'  ^-"'"' 
''-  -rors,  1  .,,,„,,,  a.e  e  L  "^^  ^°  ^^^■■"'"-' '  ''"t 
-"■-  ^•'---  As  a  .;,.en  f^  T"""""  ''"-'^'"'"t  -ho 
-^■k  relief  until   tl.e\sn.;pton,/|,   "\        ^'"''""^^  ''"  ""' 

ftln'.nou.  nleu..-sv  the  d„..,.*:. ■        "^  ^^  ^"^'-^^  *'f  ^e.'o- 


of  ill 


"^"s«  pnor  to  admission 


y^ 


l! 


6 


THK    SIIATTUCK    LECTURE. 


wiia  "iven  as  one  week  mid  uiiiler  in  8  ciif es  ;  between  one 
iind  two  weeks.  1(>  cases;  between  two  and  thr(>e  weeks,  7 
cases  ;  one  niontli  and  over,  25  eases. 

Of  tlie  symptoms  f(H-  which  they  sought  relief  the  fol- 
lowing were  the  most  striking  :  In  two  cases  no  history 
could  he  obtained.  Of  the  remaining  r)G  cases  the  symp- 
toms for  which  they  soug'it  relief  were  as  a  rule  cough, 
dyspn(L'a  and  pain  in  the  side  ;  more  rarely  fever  or  cliiils 
and  t'tivcv.  Tims  in  4f>  cases  tlio  patient  complained  of 
eougli  ;  in  41:  of  dyspncea  ;  in  11  of  pain  in  the  side  ;  and  in 
11  tliere  was  a  history  of  ciiills  and  fevc;-.  Cough  and 
dvspncea  are  by  far  the  most  frequent  causes  for  wliich  the 
patient  seeks  relief  in  lnqiital.  In  two  only  of  the  cases  did 
the  patient  gave  any  definite  account  of  an  ex[)Osure  to  cold 
or  of  a  wetting.  As  stated,  the  onset  is  no  etiological  crite- 
rion, and  the  claim  at  present  is  that  a  great  majority  of  the 
cases  of  i)lcurisy  a  friffore  arc  in  reality  tubercidous.  In 
the  history  obtained  from  the  patient,  however,  there  may 
be  very  suggestive  features  ;  lor  instance,  cough  ar,d  lo.-s 
of  weiiiht  for  some  months  previous,  or  hiLMno[)tysis,  or  u 
previous  attack  of  pleurisy.  Thus,  one  patient,  Case  1  of 
the  series,  had  had  a  cougii  at  intervals  for  three  years,  and 
when  admitted  the  right  side  of  the  chest  was  full  of  greeni.-ii, 
sero-purulcnt  fluid.  After  many  tappings  he  imi)roved  very 
nuicli,  and,  though  the  cough  had  persisted  for  so  long, 
tiiere  was  no  sign  of  pulmonary  disease,  but  subsequently 
bacilli  were  found  in  the  expectoration.  Another  inter- 
esting;- case,  No.  4,  had  luvmoptysis  nine  months  bcfoi'e, 
and  though  he  wa<  an  extremely  robust,  vigorous  man,  tin; 
insidious  onset  ot  the  pleurisy  led  us  to  suspect  tuberculosis. 
Bacilli  were  demonstrated  in  the  exudate.  The  patient 
subsequently  developed  pulmonary  tuberculosis.  In  tuo 
instances  only  the  patients  had  pleurisy  with  effusion  pre- 
viously ;  in  one  five  months  before  ;  in  the  other  eight  yei.rs 
before.  lioth  did  well,  and  both  were  discharged  at  the 
end  of  three  weeks. 


js  ;   between  one 
1  three  weeks,   7 

it  relief  the  fol- 
eascs  no  history 
cases  tlie  syni[)- 
s  a  rule  cough, 
ily  fever  or  chills 
t  complained  of 
the  side  ;  and  in 
):•.  Coii^h  and 
es  for  which  the 
V  of  the  cases  did 
ex[)Osiire  to  cold 
etiological  crile- 
it  majority  of  the 
uhercnioiis.  In 
\ever,  there  may 
,  cough  and  loss 
haMno[)tyBis,  or  a 
itient,  Case  1  of 
three  years,  and 
s  full  of  greeni>li, 
he  iin[)r(ived  very 
ted  for  so  hnig, 
but  subsequently 
Another  intcr- 
!  months  before, 
[fforous  man,  tiic 
[)ccl  tuberculosis. 
;e.  The  patient 
:ulosis.  In  two 
ivith  effusion  prc- 
other  eight  yeiirs 
Jischarged  at  the 


TUl!i:i{Cl-LOUS    I'l. 


KUIilSV. 


A  second 


the  f 

now  ii( 
f  tl 


point,  on  which 


acts 


J"^^tify.  i«  the  tlimilv  1 


"""•e  stress  has  been  hU]  tl 


o 


.i^f'erally  acknowledged  to  be  of 
le  L'criii  ifj.Jc       T         1  ,.  - 


>•"■'"  '''S''If.      Local  cond 


lan 
incjc  is 
ii  ■susceptible  soil,, -arclv 


"^^^"'■y;    hut  inherit 


""P»''f"nce  in  influencing  the 
agent  so  widely  disfused  as   tl 
18  interesting  to  note  tl 


'tions  are  probablv  „f 


'iisceptibility  f 


most 


t  of  tul 


o  !iii  infectious 


'ereuh.sis.      Still  it 


in  tl 


le  ascendants 


'0  presence  or  absence  of  tubercul 


'"•  near  relatives  ;  tl 


losis 


e'gl'f   cases    the   fhther  died  of   tJb 
'"■'  '.  "'  ""«'  tl'c  father  an<l  m„tl 


;  tluis  m  two  of  the  fift, 


niotl 


sister  :    i 


>    1"  "lie,  a   broti 


lerculosis  ; 
ler;  in  ,six. 


in   f 


our,  tl 


le 


lei 


uncle 


•"•J  i"  two  the  wife  died  of 


>"d  sister  ;   i„   f, 


1)111- 


husband.      fn    'i?    ^f 


th 
'ercuiosis  in   the  fainil 


tub 


and  in  tl 
Third 


tuberculos 
cases    pos-'ive    quest 


fi  brother  or 

■'III  aunt   or 

"^.   in  one  the 


y  were  answered  in   f| 


"•^■c  't  could  not  be  obtained 


ions     ;)S     to 

le  negative, 


Ti 


lere  is  noti 


<l'e    character    and 


effusion    i 


niir  s 


contents    of    the 


'pecific  in   the  physical  cl 


exudate. 


"    tuberculous   p] 


i'^ixnition  a  definite  opinion  can   I 
"lily  he  sero-fi|„i„ 


leurisy,   noihii,"'  fi 


li'iracters  of  tl 


le 


■om  wlucl 


»'is,  simply  serous.   1 


'u  formed.     Tl 


I    on 


'c  exudate 


l'""'J^-"t  or  purulent.      Of  these  tl 
'""  ^'■'•"i-'n.lent  may  be  called 
ol  acute  pi 

tinged.      Oft] 
found 


la'morriiayic,   8e 


10  lui'morih 


ro- 


ii,'-i'io  and   the 


■urisy  with  elfu.^ 


s'iggestive.      Of  I) 


iie  cases  from  tl 


'""  'It  'he  clinic  se 


le  eases 
ven  were  blood 


tl: 


post-mortem,  in  fom-  tl 


ese   two  were   tubereul 


Inn 


sero 


:l'""'"'''-""t  exudate,  a  little  oi.al 


,'reeiiisli  tint,  and  whicl 


'c  ^vards  in  which  pleurisv  wa 

^  ctfusiou  was  lia.m..rrhagic  ; 

■o  were  simple.      The 

paleseent,  often  with  a 


<Ji<s  and  tw 


ffy  matter  and    only  a  (bw  1 


'  '"•'•'•oscopicnily  contai 


of  a   tuberculous  le.- 

so  nirieh 

first 


<'sion. 


'I'l 


lis  a  granular, 
cry  suggestive 


i:'-'":'i^<^''  "f  late,  yiel.l  variabi 


place  it  is  conceded  that  tl 


cucocytes,  is  v 

"ccover-slip  and -ulture  tests, 
le  results.     Li   the 


cuioiis  sero-fibi 


"lous  effusions 


'c  .ii:rcat  majority  of  tuber- 
are  sterile 


"either  tbund  on  cover  sli;  '"^^.^^^'•"^  ^    «>'-^'U'isms  are 

g-wi..  cultures,     aj^   '"'""""•"''""  ""^^'''"^ 
^  "'   """   '-'^P'^nence  is  in  aecord  with 


8 


Tin-,    SIIATTrflC    LF.CTUUK. 


tilis,  excei)t  tliat  in  one  cas-e  tlie  tuhLTcle  Ijacilli  were 
(lefinitoly  dotenniiicd  in  tlio  exudate.  Tliin  was  after 
repeated  tappings.  A  sterile  efliisioii  is  regarded  as  a  point 
in  favor  of  the  tuI)erculons  nature.  In  tlic  [)urulent  tuber- 
culous exudates  tiic  bacteriological  results  are  al-^o  variable. 
In  some  i>f  tlie  acute  eases,  as  in  one  which  I  sliall  describe 
shortly,  the  Iiaeiili  of  ICoch  were  abundant.  In  otiier 
instances  only  ])us  organisms  or  the  diplococci  are  ])resent, 
or  there  may  iie  no  micro-organisms.  A  more  important 
and  more  satisfactory  test  is  the  inocidation  of  the  exudate 
into  the  peritoneal  cavity  of  guinea  pigs,  experimenls  whieli 
in  the  hands  of  some  of  the  Frencli  obser\xi>:  ha\(;  yielded 
positive  results  in  the  scr()-fil)rinous  and  [lurulent  pleurisies 
of  individuals  apparently  not  tul>erculous. 

When  i'Coch's  tuberculin  was  in  vogue  it  was  hoped  that 
it  might  at  any  rate  give  us  a  means  of  Dositive  diagnosis. 
The  rei)ort  ()f  the  (ierman  hospitals  shows  that  in  ihe 
subjects  positively  tul)erculous  the  great  proportion  of  them 
present  reaction,  wliereas  in  susi)ectcd  individuals  rJ'Mit 
(!()  per  cent.,  and  in  non-tuberculous  subjects  only  al  w. 
25  percent.  Subscquer.tly,  in  speaking  of  diagnosis  I  ,ill 
narrate  an  instance  in  which  the  acute  reaction  to  tuberculin 
led  us  into  a  serious  error  in  diagnosis. 

And  lastly,  the  nature  of  the  pleurisy  may  not  be  ap- 
parent for  months  or  years,  when  the  onset  of  ii  tubercidosis 
in  other  parts  may  indicate  cleaily  the  character  (jf  the  whole 
pr  leess.  You  are  all  familiar  with  the  striking  statistics 
published  of  late  years,  none  more  interesting  than  those 
bv  Dr.  N'incent  Bowditch  fron)  hij  father's  records.  Such 
statistics  from  private  practice  are  of  infiniteiv  more  value, 
as  a  I'ule,  than  those  from  hospitals.  The  time  li.is  !)een 
altogether  too  limited  at  the  Johns  Hopkins  Hospital  to  deter- 
mine, even  if  we  coidil,  the  sulisequent  history  of  the  grcii 
proportiiin  of  the  cases  of  sero-fibrinous  pleurisy  which  ha.o 
been  under  treatment,      it  is   interesting  to  note,  housv," 


e  l)iit'illi  were 
liirt  \\;\ii  after 
rded  as  u  point 
)uriilont  (uher- 
^  iili'o  viirialile. 
r  s<liall  (Irscribe 
rit.  In  otlier 
ci  ai'c  prcsont, 
lorci  important 
if  tlie  exudate 
crinicnis  wliicli 
>:  liiive  yielded 
uleiit  pleurisies 


lay  not  be  ap- 
f  a  tuberculosis 
er  or'  the  whole 
ikinir  statistics 
ing  than  those 


TUnKKCULOUS 


PI.EUKISV. 


in  strilv-inn-  contrast  to  f5ir„,es  f 


ii-  as  our  I'eeoni 


^^'■qii-ntly  had  tuhercul 


IS  ?,"),  only  five  of  tl 


'•"'>i  .'^nnie  hospitals,  that 


so 


it-v-^e  patients   i,ine  sub 


'•»}•  no  means  in  favor  oft! 


"«'■«•      While  our  hospital 


)rinon.-. 


sero-fi! 
confess  (hat 


e  view  that  a  I 


li'urc 


are 


pleurisies  are  of  a  t 


irii-eprop,„tion  of  all 


llU'l 


"I  Itrivate  praetlec  I   I 


'i'>oiciiloiis  nature,  I 


must 


■'-'.isinoly  inipreesed  by  the  i 


iive,  year  bv 


year,  beei 


.]ccts  of  pleurisy  with   eff 


'•<'qnen<-y  with  whieh  the  -u\ 


culons.      ,SueIi  eiu 


A  few  months  ai^o  I 


'Lvs  as  the  toll 


iision   siibse(jueiitlv  1 


Ul)- 


'ecoine  tub 


""■'n,^-  are  not  t„if 


of  fine  1)1 


SfiH'  Dr.  Martinet 


"tninon. 


Instoi 


n-.q..o  and  general  ;,ood  health,  and  exeell 


•y-     In  t! 


f  a  man   aged   40, 
■nt  family 


",  '"'."■"^'-  "f    ^^'■^■■^  I'e  <Ieveloped,    wi,| 


""^"'>"«  c-ause,  pleurisy  on  the  right  si,I 


■MS  seen  on  several  oecasion 
was  aspirated  twiee  and  mad 


V 
'(!,  and  in  tl 


hoiit 


illHl 


i-esuined  his  work.      Tl 


s  ''.V  Ih:  W.  s.  Tl 
<"  a  very  satisfactoi 


lis  attaelv 
He 


layer 


■y  recovery. 


veloped  basil 


"•CO  months  subsequently  In  ,U 


Tl 


cli 


L're  was  nothi 


"•"H>n'ng;ti.,ofuluchhediedi„tl 


"ir  in  the  cond 


■"•>cter  of    tlH,   pleu, 
tuberculous  nature,  but  tl 


if'O"  of  this  patient 


.V   to    justify    the 
'le  onset  of  a  niei 


rec  weeks. 
<>i'  in  the 


"  '""-^  ^•""'•■^«  Ji'<«  tl'o  tuberculous  f, 


suggession    of  a 
lingitis  which  .■■.„ 


etc.,  rendered  pretty  clear  tl 


'■Ml,   with   St 


ral 


vei 


•y  similar  ease  I  remember  in  tl 


H'   nature  of  the  p,.„e( 


il-.lS, 


leiigue,  Dr.  Ross  of  :\r 


wit  I 


mtrcal. 


'c  praeti.'e  of  my  1 


ai(!  col- 


'  pleurisy  on  the  left  side  and  the  I 


l"'eviousattacksoveralm..ntlisl 


young  man  w; 
■listorv  of  h 


•liniinished,  but  si 


of  tl 


^ns  of  local  d 


IS  before.   The  effu 


admitted 
ivin^'  had  a 


'e  right  lung.      About  tl 


'sease  developed  at  tl 


;'"•"  ent  ..titis   media  developed  on    tl 


ii-ce  montl,-^  after  ad 


siou  gradually 


10  apex 


mission  a 


niiiireal 


'iiortly  by  me 

l'i'''l  "-eck.      The^auto.isy'sl 


'0    left  side,  followed 


ineiiibr 
liloiis   li 


fines  on  the  left  sid 


yiiiptonis,   of  which  he  died   i„    .;I 
'"'^v-ed  greatly  thickened  pleural 


le 


It>,  many  tubercles  and  local  tul 


onions   liseasc  at  the  ri-rht  anov    ,v;.I       .    ,      "  "  ,' '"""'- 

meningitis.  '  '      '  " ''''  "  '"^^ereulous  basih.r 

I '-e  seen  recently  a  young  man  with  an  advanced  pul- 


10 


TUK    SHA'rrUCK    LKCTUlfK. 


I 


! 


inoiiarv  tiiberculosi.-,  wlio  cnnsulted  me  tirat  in  I'liiladelplua 
in  October.  18<S8,  wlien  he  had  tlie  left  pleura  •'>dl  to  'it 
chxvicle  witli  a  >er<)iis  exudate.  There  is  no  tultoreuh)U8 
historv  in  his  tiuuily.  The  dii^ease  set  in  in.-iidiou8ly  with 
couiili.  He  was  tapped  hut  t  i; 'e,  and  i»<:  lapidly  gainetl 
iieahli  and  strengtii.  1  did  i.ot  ,>ee  liiin  again  prot'cssionally 
until  tlie  aiitHu\n  of  LSi)2,  when  he  liad  li  id  iuaclii  "i' 
i^evere  prostration  and  si\ortness  of  breath,  but  very  little 
fever,  hince  tlien,  sr'igns  of  local  disease  have  \K'vel  iped 
and  extcnitd,  am}  tu!)ercle  bacilli  are  present  in  the 
ex[)ectorati!>ii.  (' ;^<•a  such  ks  these  could  be  paralleled 
I'roni  the  iiuu'  b.^iks  of  any  physician  in  large  })ractice. 
The  cases  from  ti;o  wards  which  have  developed  puhn xiary 
tubercu!u.-is  '.vii;  be  described  later. 


II.     Clinical   Tyi'es. 

Tul)e>-cuIous  pleurisy  may  be  part  of  a  general  milian 
infection,  but  it  is  rare  to  find  tiie  pleuritic  symptoms  dom- 
inating, or  even  pronoimccd  enough  to  attract  attention. 
In  reviewing  any  large  number  of  eases,  the  character  ot 
the  onset  and  the  quick  or  slow  course  offer  the  most  valu- 
able features  for  classification,  and  separate  two  types,  to 
wiiich  may  be  added  a  third,  when  the  pleurisy  forms  part 
of  a  general  serous  membrane  tuberculosis. 


.  i 


].  Acute  Tuberculous  Pleurittij. 
It  is  difficult  to  say,  in  our  present  state  of  knowledge, 
the  proportion  of  instances  of  acute  sero-fibrinous  pleiu'itiv 
due  to  tuberculosis.  The  cases  are  rarely  fatal  ;  a  large 
majority  recover  completely,  in  a  few  the  condition  becomes 
chronic,  a  variable  number  develop  tuberculosis.  ^lore 
than  tills  we  cannot  say,  but  clinical  and  anatomical  st.'  U- 
enable  us  to  separate  at  least  three  groups  of  tubercui  -■• 
cases  in  which  the  o:;.^^t  is  acute. 


TUBKKCULOUS   ri^KUIMSV, 


^  ......c,,-,,:;'!;;;:';::;;;  ■  "x; '- "'°  ■*•  '--• »"«". 

'l'0'«  I.C  ....,.y,l,i„„  i„  „,„  „  "  •'    ■  "'!>■     ^»r  may 

cxci.o  ,„,,,,:„i„,,  "  Tl,c  off™  '""""  ■■"  "'"  •" 

■     ^  ,  ^  ettiision  aii"-iiipnf<  .,,,,1   ♦! 

■«    t"PPe<I,    perhaps    .-epoatcllv      ..T  '"'"'"' 

nsv   may   recur    ..,,,1  ♦)  P'eiiia.      Il,en  tlie  u]ou- 

^,  ,^^  .jj_^^^^^    1  i-na  ju.t  about  a  year  aft.r  ti.e  o„«ct  of  the 

Case  1 Pleurisy,  loith  acute  onset-  nh.      • 

'"■'•■'II    "     ../e„A.     aur.a°^\^Z  7"-     °^ 


M 


!f 


12 


TItK    SHATTITK    I.KCTUIIK. 


to  Viri^iiiia.  ;iti(l  wliilo  tliorc,  in  .Imiiiarv.  Iiis  iiroHcnt  illness 
benjan.  Wliilo  at  work  on  a  biidiio  lie  felt  dizzy,  had  a 
severe  pain  in  the  left  side,  followed  by  coiiuii,  siiortness  of 
breath,  iiuieh  expeetoration,  whieli  was  not,  however, 
blood  tinired.  lie  went  to  a  hospilal  in  ^\'asllin^■ton,  and 
was  told  he  had  ty|)lio-|)nciiiiionia.  He  had  liiyh  fever,  and 
was  evidently  very  ill.  The  feet  were  swollen,  and  he 
had  at  times  heavy  sweats.  lie  was  several  months  in 
hospitiil,  and  was  eonvaleseent  only  al)out  a  month  before 
bis  diseharue  on  fTiine  2d.  lie  does  not  give  a  very  elear 
iiccmmt  of  bis  syni|itom8  while  in  the  hospital  at  Wash- 
ington, bnt  he  had  eoiigii  and  jiain  in  the  side,  and  be  lav 
prineipally  on  his  right  side.  He  lost  also  a  great  deal  of 
weight. 

Condition  on  admission  (by  Dr.  Thayer)  :  Patient  is  a 
large  framed,  miisenlar,  fairly  well  nourished  man.  lie 
Is  propped  lip  in  bed,  inclining  ehicfly  towards  the  left  side. 
Lips  and  miieous  membranes  of  good  color  ;  res[)irations 
rapid,  o-2  ;  pulse,  128,  regular,  tension  rather  high;  radial 
vessels  are  somewhat  sclerosed.  Temperature  on  admis- 
sion, 0!t^  ;  weight,  175  pounds. 

Inspection.  Thorax  ;  the  left  side  looks  larger  and  move- 
ments are  niiieb  restricted.  The  cardiac  impulse  is  seen  to 
the  right  of  the  sternum. 

Percussion  gives  clear  resonance  in  the  right  front  as  far  as 
the  third  rib,  where,  close  to  the  sternum,  in  the  fourth  and 
fifth  iiiters[)aces,  it  becomes  fiat.  ()n  the  left  side  tluMc  is 
modified  resonance  below  the  clavicle,  shading  into  absolute 
flatness  at  the  second  rib,  in  the  erect  posture  ;  at  the  third 
rib  when  recumbent.  The  flatness  extends  over  the  whole 
of  the  left  back.  Tactile  fremitus  is  absent  over  the  tint 
region,  and  the  breath  sounds  arc  distant  and  tubular.  On 
the  right  side  they  are  clear,  loud  and  breezy.  The  heart 
sounds  are  heard  best  to  the  right  of  the  sternum,  and  are 
clear,  the  second  loud  and  sharply  accentuated. 


n  iir<'sciit  illness 
It  (lizzy,  Iiiid  !i 
;li,  sluirtnesa  of 
not,  li()\v(!V('r. 
Msliinutnn,  and 
liii;li  f'ovcr,  and 
Adilfn.  and  Iii> 
cral  ni(intli8  in 
I  inoiitli  before 
ivo  a  very  clear 
pital  at  Wa.-ili- 
de,  and  iie  lay 
a  jj;reat  deal  of 

:  Patient  is  a 
ed  man.  lie 
Is  the  left  side. 
r  ;  respirations 
jr  high  ;  radial 
arc  on  adniis- 

rjrer  and  move- 
)ulse  is  seen  to 

t  front  as  far  as 
the  fourth  and 
ft  side  theie  is 
'r  into  al)S(dnfe 
; ;  at  the  third 
over  the  whole 
it  over  the  Hat 
tid)iilar.  On 
V.  The  heart 
rnum,  and  are 
d. 


TunriKcuLous  plruuisv 


Ex 


13 


i""inatIon  of  tlie   .dxl 


"■'"  '''c'"-,  yellow,   acid,  f 

t; 


"Mien  was   negative.      'J'j 


lint   tra 


patient  was  aspirated,  and  1 


ee 


I''   iirinc 
>i  iilhnniin,  no  casts. 


'^iiiiin  withdra 
For  the  f 


wri. 


''"()  eo.  of  ji  ,.| 


'■ill',   vcllow 


iii't    inateriall 


''■•"t  iiioiitii  in  hospitjil  tl 


mndt 


to    1 


y    improve.       H,.    ] 


le  patient's  eon.litio,,  di,] 


'■)i 


ilwecn  US.')' 


'he    femj)erafi 


iind  loo 


""i       I"       Wcinjit       |,.,„„        ,-- 

•0    range  was   constantiv 


""t-e,    on    tin;    second    d 


'  '■••'I'oly  goiny  to  ]00 


101. 


tiii 


(in 


The  fluid   gradnall 


i'.v    after    his  ,,(1 


•">'^,  and  oidy 


imssmn,    reaehin"- 


)pe(l  on  (lie  21st 

the  ;iOth,  when  1000 


I'l'-fUXMimnlafed,  and  I 


10  was 


'"'ill,   when    1100 


.^;v'th  a  withdrawal  of  12,S0ee.,,fH,,i,] 
'^vn  ;   and  on  July 


cc.  were  withdr 


cc.    were   rei 


wgan  to  improve,— til 
In  wei 
made  : 


nove( 


J.        Karly 


^■'it.      On  the  third  of  A 


e  appetite  increased,  and  I 


ill    .Tiilv   he 


Tl 


"giist  the  follow 


;c  patient  has  heen  aspirated  in  all 


^t  time  heing  „„  t|,e  2(Jth  of  J„l 


IS    now    very 


iiKirlved    tlatte 


() 


le  gained 

ing  note  was 

six  limes,  the 

'11   inspection,  there 


expansion  is  greatest  on  the  rioht  Sid 


'"•ng  of   the   left    front.      Tl 


le 


"I'fo  is  full  and  el 


IU)OV 


ear.      On  the  left  side  tl 


e,  on  which  jierciission 


■e  the  second   rih,  below  al 


lere 


1:it  areas  there 


>inne  intensity  evervw 


ibsoliite   flat 
i«  a  distant,  tubular  breati 


I  ere. 


i^^l'cd.     The  breatl/so.md 
spiniis    fossa."       H 
August  the  ;',nl,  witi 


Tl 


10  vocal    freinit 


is  Hat  tymj)any 

ness.       Over  the 

liiig.  of  almost  the 


'  ^fiy  nearly  absent  in  tl 


lis   is  dimiii- 


•-    H-as   aspirated    tl 


lie  supra- 


I  removal  of  800 


'""<•  "11   August   Kith,   when    ( 


li'l  "f  the  last  f 


:oo 


[Oil 


'■'ff''''  r'"f  of  July  and  the  f! 
'''"l"'-ve<l  rapidly  and  gained 
"•eighed  17,-»  pounds. 


'•  tappings   was  blood-tin-,.,!.       J 


I'st    two    week 


le    <?eventh    time    on 
«••,  and   the  eighth 
moved;    the 
n   the 


CO.    were  re 


■■*   111    August   he 


'"    weight,  and   on   the  KJth 


Tl 


le 


patient  was  discharcred 


""-v'"y-"ote  was  made:  "  The  left  siJe  of  tl 


'^oiiicwhat  sunken  ;   right  sid 
'"'j'^s  large.      At  the  left  apex  tl 


le    cr; 


111  August  18th,  when  the 
16  chest  seeins 


■  ■"(!«  fully  and  well,  and 
IS  a  flat  tympany,  which 


14 


TH.:    SI > ATM 


LKCTIUK. 


.«Iia(lo.s  into  fluiicda  III  the  fiCtli  rih,  just  (.iitsuJc  the  iiiiipl,. 
lino.  At  till'  loft  back  tlu;iii  i,s  a  iniirkod  diilnetis,  becoinin- 
!il)M)liilo  iilx.iit  nil  indi  below  tlio  aii-le  of  sciipuhi.  Abovo 
tbin  point  (he  vociil  fioinitii,^  Ls  Mt,  boh)w  it  is  absoiit. 
Kcvxpinition   is  board,  thou-b  fuel-'  ,ere  except  at 

Ibe  extreme  base.  The  point  ol'  iiiaxiimini  eanbac  impujsi. 
is  not  to  be  made  out ;  the  sounds  are  lieard  distinctly  over 
the  normal  area;  the  second  pulnimiic  sound  is  "accen- 
tuated." 

'I  lie  diagnosis  of  pleurisy  with  effusion  was  nnide.  No 
suspicion  was  entertained  by  Dr.  Thayer,  under  whose  care 
be  eanie  durin<r  my  absence,  tliat  the  |)rocess  was  tiiber- 
cul  -us;  indeed,  tliere  was  no  evidence  whatever  to  indicate 
this,  excci)t  tliat  tiie  Jast  four  tappings  were  slighily  |,]u,ni 
tinned. 

November  30th,  1892.  Patient  was  re-a.bnitted  to-.lay 
with  dyspno'a,  rough  and  fever.  He  states-  that  he  lias 
remained  well  since  discharged,  August  1-th,  and  has  been 
working  on  the  streets  ever  since.  Three  week;*  ago  he 
had  slight  shortness  of  breath  after  an  unusual  exenion. 
and  ever  since  that  has  had  slight  cough  with  white,  frutiiy 
expectoration.  He  worked  evov  day  until  November  MiU. 
Last  evening  he  bad  a  heavy  chill,  in  which  be  shook  lor 
an  hour.  This  was  followed  by  f.-  r,  whicii  oersisted  all 
night.  This  mo.  v..  he  ,.it  up  a  ..ile  blood.  His  appe- 
tite has  been  trood. 

Condition  on  admission.  AVeight  is  nOjjounds.  'IVni- 
perature,  ]()0.4  at  2  v.  m.,  rising  t.  ;  03°  ai  4  i-.  m.  IL 
bad  a  profuse  sweat  in  the  afternoon,  and  the  temperatu- 
fell  to  tiso  at  0  o'clock.  Pulse  rang.  1  .rom  80  to  l:.'ii; 
respirations  from  18  to  3(J. 

December  1st.     Tliis  mornn,      pat'    it  is  lying   on      .- 
back,  face  somewhat  flushed,  Ii|      am.      uicous  men.briinr. 
and  finger  tips  somewhat  cyanoiic.       J'ulse  104,   lull, 
fair  tension.     Itespirations  32.      There  is  marked  flattening 


(nils<i(Ic  tlic  iii|i|i|(' 
(liilnetis,  l)i'C()iiiin;4 
'  so'jipiilti.  AI)()Vt' 
jIow  it  is  iil)SLMit. 
mre  except  ;it 
III)  cardiac  iiiipiilsc 
ird  (llotiiu'tly  u\cv 

sound    is    ucccii- 

1  was  made.  Xo 
under  wliose  care 
rocess  was  tuljcr- 
latever  to  indieate 
ere  slightly  Idood 

e-udniittcd  to-dav 
tates  tlmt  lie  lias 
■^tli,  ami  has  been 
•ee  week8  ago  lie 
miusual  exertion, 
(vitli  wliitc,  fVdtliy 
1  Noveiidu'r  I'dth. 
lieli  he  shook  t'or 
hieii  t)ersisted  all 
lood.      His  apjie- 

0  pounds.     'J'eni- 

°  ai  4  1.  M.     lie 

the  tcniperatiiij 

loin  yo   to    k'll; 

is  lying    on     ,.- 
icons  ineinhranc.-. 
Ise  104,   full. 
narked  Hatteninji' 


TL'nKl!Crf,OU,S    IT.KliMflr. 

^::^i..":tir 

''-•'-''^''''-h-  i.: ;  :,f^''^t''^'''"'''^''''•''''^'''- 
nmllein,hne,ri  :,:       r-     ."'■■   "™-     i-t   in   :. 

II,,,,,..  '',    ^  ■""'  "''f'""^'!  Hear  f|„i,|. 

"'"t;    "C'lM.arkedepiga.tHe  in.md^o       Tl 
'■"I'"'''«  t-'H.not   he    u,„de   out        'V  ,  "'"  '""-^•""""> 

'-•"   '-''0   fourth   int.;     ./    :  7""^  :--''^    '- 

encapsulate.!    '■    lueocci.  ''•'uih,  and   many 

,  '1''^ '"■'■'HN 'eddish  hnnvn,8p.,.,.    lo->-,    ,.,    , 
"f  ""'"M.in,  not       :p,,sts.  '-'' "Xylonite  am.Muit 

I>m.mher  ;i,)        U  ithi, '  ,he  n,st   'Ml 
'■""^"li'lHtion    have    -.nn,             •                    "'""'  '''"^  ^""-"■^  "^ 
--ded    rapidlv.  ,    ;>   "'-i.'.t  .ide ,,,,, 

''-''  N-ace    u   ;V,,n,    ..''';-  ;'"'"'^^^   '''-'-   "^    ".0 

' '-•■""><••  -^'^e  \:a.i:  ;t:' :  ;^:^r'"  r ''*' 

r"-^- '''••-•"i-'-'-'-^i.H^c;; :  ::,^'''';:!^^ 

t-"pora.ure  rose  throughout  Deee.nher  1  '"' 

1"^=-M0fio.     For.he.::;   oM     """"I" ^'^^    ''^'-- 

'-nvecn    10;3o„„,,    „^" '',^  "'^  '—-^  "--•'•"!..-  has  heen 

"'- i--.y,i-:;;n  L  ::::;• '''--'"^-  ti. 

"'•  ^-'--ingonoJ,  ;;,:;:::■;:: -'-^^ 

"iis  practised.  ^       "'""c'-'te  venesection 

""'"""""-     ■^'"^'  ""'■-  '— o.u.e,U„  „.,  ,,„,„ 


Hi 


TIIK    SMA'IflJCK    I.KCTUUE, 


side  hcliind, 


tin 


(1  tlioro  is  now  tiihiiiar  lnvalhinLi:  'Vom  (1 


H|)in.'  ^,\^  ill,,  sciipul     to  tho  1.(180  ;   pulse   is   o-,„„I 
lieratuiv   (ell   |i,,.(   evening-- to  lOl     ;   this  niurnin'' it  is  hi' 


It' 


tl 


ic   teni- 


ain. 


KM 


'I'l 


(I  I 


le   rcppiiatioiis   are   ai.oni     l(».     Ti 


icrc  j. 


marked  Iciieocyto^Ks,  ;j;i. ()()()  wliile  corpn-cKvs  per  ciil 
Dining'  the  day  patient  sank  i^nadiiallv.  ,iie  imLse  1 


lie  mm. 


lie  piiKse  lieeoniiiii; 


f'eel.le,  in  spite  of  tlir  pci  sistcni  adminiMration  of  »<tinndant 
■•'""iionia.  etc.  ;   the  temjieriiture  kept  np,  ami  he  sank,  ami 
died  at  :.'  .v.  m. 

Autopsy  (Dr.  Fh^Nnor).      I'.ody  of  a  lai-e  framed. 


Weil 
I'lrax  ;    universal 


noiirislicil  iiKin.      reritoneum  fuiootii.      T 

iilliesioiis,  wliieli  were  readily  stripped  oil' on  the  ri;;i|it 


On   the  left   side  d 


ense   lihroid   iniion  of   the  I; 


pleura  to  a  distance  of  ahoiit  8  em.  from  the  sternal 


sale 


ivers  of  tl 


The  heart  miicli  distended,  with  firm  in-]: 


margin. 


tiiiouM  clots  ;  1 


ii<i(| 


crate 
of  th 


IK'rlrophy  of  the  left  ventricle,  distinct  hypcrtriM.hy 
le  ri-ht.  the  walls  of  which  weiv  firm  and  consider 


iiilv 


thi 


c!\cr  than  norma 


1.      \ 


o  eiuiocardiii- 


III  rciiioviiii-'  the  left  lim-'  an  encapsulated 


•eroiis 


Iff 


IISKJll 


was   opciHd,    (Hriipyiii,--   the   layers   of  the    pleura   over   tl 
postero-lateral   renion   of  the  h  ft  chest.      Tl 


le  costal 


pleiirii 


was   ureatly  thickened,  ranjiinn;  from  1  to  l.f)   cm.;   at   t 
diaphiauiu,  it  was   in  places  as  much  a- 


cm.  Ill  thickness. 


inc 


The  visceral   layer  was   also   thickened,  l.ut  not  to  the  sa 
degree,  only  from    ;!    to  r>  mm.       15oth  layers  were  smooth 
g-reyish  white   in   color,  in   places   present 


\u'<:  areas  of 


con- 


gestion  and  ha'morrhaye. 
white    irelatiiious    lihriii    i" 


Th 


're  was  a  i^ood  deal  of  y- 


revisli 


\isceral  iilcura. 
caseous  infiltrat 


Tl 


pfaccs,  close 


ly  adi 


lerciit  to  the 


lere  were  no  caseous  masse 


s,  no  s 


[Hits  of 


1011  on  the  surface  of  either  layer.      () 


tion,  the  thickened  pleura  hail  the  appearance  and 


d   fin 


11  sec- 


eonsislciicc 


as  1 


fill 


II,  new  eoiiiicetive   tissue,  and  at  first  siylit  it  seeiiicd 


le  process  were  really  a  simple  chronic  pleurisy,  , 


iiore 


particularly  as   no    miliary   tuhcreles   were    noticed 
surface,   and  no  caseous   masses.      On  close  examinatiui; 


on   the 


K. 

rt'Mtllill<r    I'roill    (lie 

i-*  f,ntu(l  ;  tlie  toin- 
innriiiiiii'  it  id  lii^rli 
ml  10.  'I'lin,.  i- 
cIlvs  |icr  ciiltic  iiiiii. 
lie  [ntls^e  l)('i!(iiniii- 
tioii  ()(  Ktiiiiiil.iiit-, 
iiiul  iio  .-link,  ;ini| 

ar^e  fViiiiicd,  wi  1| 
!i<irii.\  ;     univeiMil 

i>ii  the  lijulit  Slide, 
liiu  Id  vers  of  til,. 
10  .■'IiTiiiii  niMi'nin, 
nous  clotiH  ;  iiiud- 
tiiiet  Iiypoi'lroriliy 

iiiKJ  OdiisidLiiililv 

I'd  .-crouH  otfiisidii 

piriira  over  the 
I'lu;  coj-tid  [ilciira 

l.'>  cm.  ;  at  the 
I'm.  in  tlu(diiu.'iii.s. 
;  not  to  llie  .sunc 
?rs  were  .smooth, 
\'^  areas  of  ('(im- 
d  deal  of  yrcvisli 

adiiereiit  to  the 
IfSOf,  no  .xpnt,-  of 
layer.  On  t;o(.'- 
i  nnd  oon!«i.-i(.iK'e 
(^iglit  it  seeiiial 
c  iiieiirisy,  more 

noticed   on   the 
so  exanunatiiin, 


'TllimvVLOVS 


i'Ly.VHISY. 


'"'*^<'VtM-.   of   (Ih,  ,.„t 


^'■•^"■'•ns,  pariicularlv  in  pj 


•'■•"'^'"'••"t  fibroid  tuhercle.  eould  I 


places,  L!ieyi.«li 


"le   eut   Niiif 


aces. 


'J"l 


""<-''««i..d  dia|.|,n,;.,„„ti..  J 


ic>e  wen 


were 


"imd  siiiidl  III 


iNcrs. 


'e  '^ecii  |,n,i,.,.tin^  ,,1 
l""'''<''darly  marli<.d   in  d 


!)ove 


At 


vc 


»*■  liiltoreiiloiis  infill 


■*'"'■',  from  ;i  ( 


"lie  or  ts\,, 


'|)Ot8  tl 


lere 


'•';;'"'•  in  extent,  of  .,,vi«h. 


I'oiisidoi'idd 


V  CO 


""'-  except  i,t   tl 


'i"|<ie«.sed,  |j„t  8,ijj 


'""""•       TI.e    loft  1 


luljerei 


L'xtrenie   l>ii 


C-*.  no  easeoii,>(  n 


it<e. 


ini,L(  wiis   verv 
''   •-'^•^■O'Hl'cre   eontaineil 


Tl 


voluminous,  retained 


iiaswc'8. 


Tl 


lere  were 


'ic  linjit   ]„„ 


evei'vui 


icre  airlf..i8 


'■'•^  «'i"i"'.   did   not    coll 


'"'  niiiiai 
ua8  laro* 


y 


.•mtero-laterfil  in 


'   L'xeept  at   il,,.  ^xt 


']'•■*<-',  and  Was 


■^•"'-      The  phMira  was   a   I 


iifMjn 


''cine    apex, 


and    tliu 


"""  <'"V.Te<I  witi,  „,..  of  ol.l  adi 


i't'i;  tliickenud. 


!>een 


() 


tion  and  .so/tcni 


"   section   there 


lesions;   no  tuKercl 


tuherelesand  small 


".if  the  ftizo   of 


"•»«  at  the  apex 


es  were 


'I  walnut. 


tlirectly  with  a  , 
upper  |o|,e,  the 
Iwfv  lolie,  wei 


cr  areas  of  caseai 


Ion, 


:oo( 


^ized  I 


Tl 


"•"iiclms.      The  I 


'"'  area  of  oasea- 
^"iiToiinded  with 
"<«  communicated 


»cre  no  miliary  tuhercl 
tracheal  ,i,'iands 


?';eater  part  of  the  middle  lol 
'■'  I"  '••  eondiiion  of  red  I 


ovver 


l>-'iit  of  iht 
"-'.  and  all  of  the 


es,  no 


here  and  the 


\vere<nx.atlv 


caseation. 


'cpatizalion.      'J'i 


Tl 


lere 


>'e  small 


«^vollen,  tumefied,  and 


'L'  l>ronehial  and 


caseous  masses.      'M 


piesonteU 


f  ^''"1  »ote  in    the   ahdoininal 


'III'  I'i-ht  testicle  tl 


<'i'"ans 


lik 


structure  com 


Tl 


'^-''-e  was  a  marked  tuherciil, 


'^■'•'Mvasafihioidandeartd 
■ii'imycholeste 


'L^i'e  was  iiothino'  of 
'"J   tul,ereles.  "in 


ti'imly.  and   tin,  Litter  t 


nil. 
)Us  1 


'.-"'uiis,  cyjt- 


"storv  in  th 


a  less 


upon    which 

less  have  laid 

P"^'i""<»iiia,  tubercj,.  bacilli 


'Pl'i'i.us   \\ere  hlooj 


patleiii' 


greater  stre.- 


I'dhlistly  hnilt 


^'".i^cd,   poini; 


Oi 


toinii 
time. 


1  in  tl 


as  wel 


'c  *<piituni,  and   the  f 


"'■in  we  would  doul.t- 
'"•"  "itii  an  acute 
!i«  pnemnococci,   w 


1  Ills  ret 


ere 


••I  definite  clue  to   tl 
■'"'""'«  but  in  process  of  | 
''■'t  tl'e  tubercle  bacill 


'"■'"«-''•  «Hve  us.  loribe/ir,l 


"-'  nature   of    t| 


lie 


Hiseation    and  suft 
elms. 


lealiii"- 
'  came  II 


It 


I'leuii 


now 


•0111  a  vei 


's  mteresiin,!--  to  note 


•y  small  i 


^•""ig  in   communication    witI 


OCU; 
il    b 


)f 


run- 


18 


THK    SUATTUCK   LECTUKE. 


(h)      The  sccondnrij  and  termhial  amte   tuherciilon-i 
]>lei(risi/. 

Here  rcfciviico   is  iidt  miulo  to  cnsps  of  ocium-mI   miliinv 
tiilKMCiilosis  in   whlcl,   the   plciirul  iiioinbranes  nro  involvcil 
with  otlicr  parts.      A  miliary  eruption  is  verv  often   .<ceon- 
(larv  to  a   h)eal    tnhenMilo.sis    in    the  Innu',  and  under  these 
ciivmns^tanees  tlie  exudate   !.-<  usually  fihiinons.      It  is  inter- 
estiiiLT  to  note  that  in  the  101  post-nioftems  from  mv  wards, 
in    the  cases  in    which   tnl)errle.s   were    found    on   the  mem- 
l)ranes  only  fom'  had  a  simple  fibrinous  ])leiu-isv.       On    the 
other  hand,  there  were  eleven  instances  of  h'hrinous  pleurisv 
in   persons  dead  of  puluKMiary  tuhercidosis   in   which  tlieie 
was  no  mention   made  of  tiihercles  on   the  pleura.       This 
accords   with   the  well   known   experience  that  a  pleurisv  in 
the  eoin-se  of  a  pidmonary  tidierculosis  is  not  always  due  t(, 
the  presence  of  tubercles.       Acute   miliary   tubereidosis  ,,f 
the  pleura,   with  a  sero-fibrinmis  or  ha'morrhagic  exudate, 
was  present  in  only  seven  of  the  autopsies.      In   every  on,. 
of  these  cases  the  tuberculosis  was  secondary  to  some  otlin' 
affection,  or  occurred  as  the  terminal  event  in    some    lonu- 
standin--   illness.        Whether   or   not   in    an    instance,    t.r 
example,  of  acute  pleurisy  with  eflfusion,  cominu- on   in  aii 
apparently    healthy  individual,  and    whie'i,  for   the  sake  >,{' 
arn-iunent.  we  may  presiune  to  be  (iiberculous,  thecondi'-  m 
ol'the  pleiua  is  that  of  an  acute  miliary  tuberculosis,  I  have 
no  personal  knowledge;    but  in  my  experience  the  condition 
lias  almost  invariably  been,  as  just  mentioned,  a  secondary 
or  terminal  process  in  some  already  existing'  affection.    The 
followin,--  arc  illustrative  cases  :     In   the  first  ii:stance  there 
was  a   chronic  auivmia,  induced   by   the   liaMnorihoids,  with 
(dd  f  ici  of  caseous  <lisease  at  the  apices  of  the  lungs.     The 
death  resulted  from   miliary   tuberculosis,  involvin<r  chietlv 
tlie  pleural  sacs. 


TUBKKCUI.OU8   I'LKVUISY. 


If) 

Ca.e  IL-~Ihumorrhoids;  unannU,  ■    1        ■ 

<^»^cons  foci  in    tk,  '"'"'  '^"-'^^'^  t^^hcrc^aous ; 

"••  S.,  male,  wliite    -Km  i    \~ 

'-'  ^'^"^"'7    '"ii"  ;    never   Jns  1  '    "'  "'^''^^'^  '>^'en 

'-"'on-l.oids,  whieh  l.ave  troubTed  1!"^   '"""'''    '''''^''  "'^• 

--.  -Hi  l.e  I.aa  J,Lt   blood     I  "^'  ''"■^'  '^-"  --'' 

;''-e  o.  fo.a.  evacuations  eve  /d       ",7  ""'^^'  '"-'".  Lad 

^"«'  "«  "'uoh   as  a  pint   of  fl      f"      "'  '''"^'^  ''''''  ''«  J'^^^ 

.-duailv  become  vcrVd      ':'  ''^  ""   ''■'-•      ^e  has 
'"•e  not  bleedin.r.         ^       "     '^'  ^''"'^-^''t  f'e  iueniorrlioids 

"•••'^  ^'ff--       Tbe  pulse"  V  r;  '",     "  '  '^'^  ''''''''  ''"P"^- 

''-'-rinecontaineda'^:       ;rV^7^ 

-'-     He   .as  thou-du  tie/    /""''"'  "^"^  ""  '"'^^ 

from  bleedin.  piJes.    "  ''"^'^  '""derate  grade  of  an.nua 

About  tlie  'iiiddle  of  V  , 

^'^^'->-N  »-t  the  ZZrZT       '"  ^""'^''^  '-^^-  ^"  l^e 

^enn-solid  stoui.  dailv.     JJe  d  '^"'  ^'■"'»  '^^'^^  ^o  six 

'•■""'^'•■"^^  i'-eoberent  way  '     ""=''  '"^  '-'^'^'  '»  '^ 

About  November  28tli  Im  I 

>l"  «e  ms  il,„t  |,e  „,„  '    ,      "^        O"  December  3d 

«"'"-  a.  0„,l,   ,,„„,,    b',„;   ,'^1^;;™"";"' "■  'Vo,,.; 
2  ",t   angle  „f  sca,iu|„  ,,„ 


c 


it 


20 


THK    SIIATTUCK    LECTUHE. 


fihsence  of  brcsUli  sounds.  There  was  no  expectoration. 
He  continued  to  iiave  tln-ee  or  four  loose  stools  daily,  and 
died  on  the  5th. 

Autopsy.  Large,  well  built,  well  nourished  man, 
marked  anioniia.  Peritoneum  is  smooth.  Over  the  mesen- 
tery, and  the  lower  surface  of  the  diaphragm,  and  in  tiic 
pelvis,  there  arc  numerous  elevated,  translucent  tubercles, 
some  of  them  surrounded  with  areas  of  hypera'mia.  Tlic 
peritoneal  surface  of  the  intestine  also  presents  numerous 
tubercles.  The  surface  of  the  spleen  and  the  contiguous 
diaphragm  presents  many  tubercles. 

Acute  miliary  tuberculosis  of  both  pleural  sues,  with 
about  two  litres  of  serous  fluid  in  each.  Tiie  membranes 
were  covered  with  a  thick,  fresh  fibrinous  exudate,  after 
the  removal  of  which  many  miliary  tubercles  were  seen. 
Both  lungs  were  compresseed  ;  no  cavities ;  but  at  tiie 
apices  there  were  old  and  partially  softened  caseous  masses, 
with  many  miliary  tubercles.  In  the  lower  lobes  there 
were  only  few  scattered  tubercles.  The  spleen  presented  u 
few  tubercles  ;   no  tubercles  seen  in  the  liver. 

Intestines.  One  or  two  small  ulcers,  witii  irregular 
margins,  in  the  ileum.  The  mesenteric  glands  iiaid  and 
caseous. 

Meninges  wore  cedematous,  but  presented  no  tubercles. 

In  the  following  instance  the  patient  died  of  an  acute 
entero-colitis,  with  an  acute  miliary  tuberculosis  of  the 
pleura  as  a  terminal  event. 

tV<w /// (abstract). — Chronic  entero-colitis ;  acute  In- 
hei'culosis  of  the  left  pleura. 
Jos.  A.,  aged  33,  colored,  admitted  Jar.uary  2.'!,  18i)I, 
complaining  of  diarrhoea  and  colic.  There  was  no  history 
of  tuberculosis  in  his  family.  He  had  gonorrlio^al  synovitis 
five  years  ago,  and  a  ciia'ncre.  For  nearly  a  year  he  lias 
been   subject    co    diarrhoea.       On    admission,  patient  was 


Hi 


ii 


f 


TLBKKCULOUS   PLEUK.SY. 


21 


ted  no  tubercle?. 


olitis;    acute  (u- 


;.'""eiate<I  an.i  ,.Hno,n;c ;    afebrile      Tl        ,      • 
''"■'■^^'-^'"■^^^    ■•"    001,.;  t:'"^'''''^''''''^^^ 

^-■-  te.npen.t.u-0  nu.,e  fV  "^p  ^UM  o  "' ;'^^^'  "'"^-^^^^ 
;;-  uncontrollable,  a„„  ,.«  a  ..^  1  ^'"  ^'^"'^''-^ 
I-.bruary   28tl,.       There  ^^..s    f     T^  ''''"'''   '""'^^   ^''^■''    "» 

■  ""-^  ^'-  entire  eo.tal^ l^  r^  T\  T'*""'  "'^^-^^->- 
"^.  ;•'"  -— -ve  eruption'  o     '  ;  ^ ''!  ^  f '  ""  "'^  ^"^ 

'•-<i''to.      Tbe.e  fresh    .,  ,.  "'"'   '""'  '""^•''   'if"in"U 

'7-enole«io„;i:,i^7:::'^^-^«-recaseon. 
^'-  '-ver  lobe,  adherent  to  til  i'lT''\  '"'  ""^  ^^^^  <^f' 
"■:-"•«  '"as.,  .vi,h  «on,e  injur  T' '^'''■•' ^^"^ '^  «'•'» 

''  f-^ry  ^ubereles.  '''""  "'^""^  '^  "'"i  colonies 

'-^"rridelirJI^Jte^lL^  -"^  .'"'""^  ^"^-- 
"■''"  ''--  '-en  'UKler  tre.  t  /  "^  '  ^'"  '"''-  '>^"  P-«ons 
''^'^^•''--    ^'f'    the    heart        d        l'  """   ^•''™"-   '"aiudy, 

f--.  or  selero.es  of  vano:^C"'r*^'''n'''^  '"'^''^'^ 
^^  ^-'-1  in  .bese  eases  ohl  f,ei  o  tul  f'  ''"'^^  ^^''^ 
'■"^-"«  "odule  at  the  apex    or  '„  />  '"^'"^"'""^  ^i^^c^rse,  a 

'"  "'^^  '"--"f-icgland..^     o    Vt       r     •""'''''  •^'^-^'«'  -• 
-I'<-'«lly  to  the  association  of  t  .1      "',""  '''"  '"^"  -"-' 

"V-  ^'-•;  but  a  nun.br'"''^"""!"'"''^'' -•'■'--•« 
?''"^-^''«  «^'  ^'-e  pleura  have   ,1  o         "'''\"  '"•'"'■"'^'  ^"'-•- 

''-7'-ntn.a,e.i;::r^^^^^^^ 

^'"'"^•1'  to  attract  uttenti.,,       r  '^  ""'"'''^  ^^^"'^^0'"^^ 

•'^''i''"-''  Ji-Pital  an  eklerlv" n.a     ';;.'■,;'  '"f  ""''^  '''  ^^'"•'- 


22 


THE    SHATTUCK    LECTUKE. 


it  liiid  come  on  wjtlioiit  any  special  aggravation  of  the 
symptoms,  proved  to  ije  actile  miliary  tuberculosis,  with 
eti'usion.  More  frequently  the  symptoms  are  pronounced, 
as  in  tlie  following  case  : 

Vase  IV. — Fatly  and  cirrhotic  liver;  hoemorrhage  from 
the  bowels;  bilateral  acute  tuberculous  pleurisy. 

Mrs.  L.,  aged  27,  admitted  with  hiumorrhage  from  the 
bowels  and  tenderness  over  the  region  of  the  liver,  wiiich 
organ  was  slightly  enhirgud.  There  was  no  jaundice.  ^Sho 
was  a  hard  drinker,  and  iiad  bean  in  failing  liealth  for  somo 
months.  Signs  of  pleurisy  were  discovered  on  both  sides, 
and  she  had  a  severe  cough.  She  sank  rapidly,  and  died 
witiiin  a  week  or  ten  days  after  her  admission. 

Autopsy. — Left  lung  covered  with  a  thin  fibrinous  exuda- 
tion, thickest  at  base  and  near  the  edges.      In  places  the 
membrane  is  studded  witii  minute  granular  tubercles,  which 
are  best  seen  where  the  exudation  is  less  abundant.     Tiie 
organ  is  crepitant   throughout,   a  caseous   sj)ot  is  seen   at 
apex,  and   a   narrow  fibroid  area  in  the  lower  lol)e.     No 
disseminoted    tubercles    tiiroughout    the    substance.       Tiie 
right  pleura  piosents   a  similar   exudation,  less  abundant 
than   on  the  left  side.     The  costal  pleura  is  thickly  lined 
with  false  membrane,  is  congested,  and  presents  small  grey 
bodies  scattered  through  tiie  membrane.     At  tiie  apex  of 
the  lung   is   a  small  caseous  mass,  with  a  cavity  th(    size 
of  an  almond,  in  direct  communication   with  a  bronciius. 
In  the  neighhorhood  of   this  are   several   small  groups  of 
tubercles.       The  lower  lobe  also  presents  a  couple  of  siiiiiU 
caseous  bodies,  but  no  scattered  tubercles.      Liver  weinhs 
2,200  grammes,  is  large  and  pale.     Lobules  distinct,  bile- 
stained    in    centre.       Organ    is    both    fatty  and    cirrhotic. 
Other  organs  normal. 

Such  instances  as  the  following  are  not  rare  in  old  lios- 


i  ! 


TUBERCULOUS    I'LKVHISY. 


ot  rare  in  oM  lios- 


PJffil    patients    ujfl,    n     ,.  '  ^^ 

'Joseph  A.     i(,r,l    7n 

.^""■■is^^.c'o,;,;,...!":  ,:;::'•  '»•""-■•  »..mi»«,  ,,„,, 

'"S  of  tl,e  fee,     .v„  f.r,„!,  ,"""='»  "f  l>'»ntl,  „,„|  ,„,„■! 
;^-     Sl,c  novc,.  |,e„,j  JI'V    '",«V""""''"'»"  »"  '"» 

"0  «f  alcohol  ,„  exce,,.      '       "'^  ""'"•     H"  <ie„i«  ,|,e 
'™-«l  V  l»ln  ,„  ,„o  ,to,  n  ,""  ""  '"""■•  ""'I  "a,  fol. 

«"'l  I'C  el,i„k,  „„  ,.|„,o„„„t  ;  =  ""-.  ^,'S«  teg,,,.  ,„  ,„„„^ 
«I«'M  11,0  „,„o  lo„«|,  of  ,i,„r       ,       "''«'"'>■  "vollo,,.     F,,; 

W  („  slco,,.  ="•  •■""I  lio  lias  l„„l  ,„  ,j,  j,|,  .^ 

I'lescit  co„i!,„-„„._j    I    ,  ,  . 

»".vco„,p,o..,,,,    ;,,::/;      ™™P".« 

i««e  nitlio  , „•„!,(,„  j(|  ,,"""'    ton|ii-i„<,„.o    |oio 

-'a.;ll,  „m.tor.  ,„  |,i„,;|f,  •     ""  "  "•"  '-"lional,  ,„„!  ,„„: 

'» ''x-;:,;;::::::r  ■'■:,:^'™''  r.  '^'^ '-« .-^  .00.,. 

f««  »eco,„p„„ie,l  l,y  „„  ,^ ,*  ''""'"■"'ions  every- 

"«=  '"'  «iJe,  are  mCi,™.;  L""     ?""    ''I"-,  "'"ol,,  „„ 


24 


THE    SHATTUCK    LECTUKE. 


sides  respiration  is  liarsli,  and  accompanied  witii  fine,  moist 
i-iMes.  Heart  impulse  is  in  fourth,  fiftii  and  sixth  spaces; 
maximum  in  sixth,  3  cm.  outside  tlie  nii)ple  line.  Ivulative 
dulness  at  third  rib.  Sounds  are  feeble  and  hoard  with 
difficulty. 

Patient  was  taken  home  August  11th;  tiie  dilatation 
of  tlie  heart  had  subsided  under  the  use  of  digitalis.  He 
had  slight  diarrhoea,  which  was  checkod  with  alum  enemata. 
The  signs  of  engorgement  in  the  lungs  disappeared,  and  ho 
had  no  pulmonary  symptoms.  The  case  was  regarded  as 
one  of  hydrothorax,  secondary  to  the  dilated  heart  ii; 
chronic  arterio-sclerosis.  Death  occurred  about  two  weeks 
after  he  left  the  hospital. 

Autopsy   (Dr.   Flexner  and    Dr.   F.  R.  Smith)— (J/,- 
slract). — The  patient  was  found  to  have  general  artcrin- 
sclerosis,  with  hypertrophy  of  the  heart.      The  pericardium 
was    smooth.       The  right    pleura    was    thickened   and  tlio 
pleural  layers  uniformly  adherent.      The  costal  membrane 
measured  about  4  nun.  in  thickness,  and  was  covered  with 
tubercles,  somewhat  larger  in  size  than  miliary  granules 
and,  as  a  rule,  caseous.      The  underlying  thickened  inlil- 
trated  tissue  was   yellowish,  and  consisted   of    a  diffusoly 
caseous    mass.      The   outermost    layer  was  more    fibrous. 
The  pleura  covering  the  diaphragm  was  greatly  thickened 
and  infiltrated.     The  lung  was  somewhat  compressed,  doep 
salmon  color,  and  contained  no  tubercles.      The  left  pleura 
was  not  especially  thickened  ;  no  adhesions.     There  woro 
small  miliary  nodules,  however,  on  the  visceral  layer.     Tlio 
apex  of  the  lung  was  somewhat  retracted, 'and  on  the  anterior 
edge  of  the  upper  lobe  there  was  an  area  of  caseous  pneu- 
monia, with  a  small  central  cavity.     There  were,  howevor, 
a  few  scattered  tubercles  throughout  the  posterior  part  ot 
the  lunir. 


A  coi 

"iited  as 

tlie  fact  i 

siii>J)Mrat 

run  a  vei 

the  diseas 

liistory,  n 

fhe  side. 

side,  feeb 

Physical  e; 

t'lo  nature 

"s/iiratioiis 

(^'ear  that  t 

"as  requet 

collection  c 

fr"in  a  mar 

"■ere  resect^ 

wi\s  found. 

'ibout  five  w 

iilceratio/is  v 

pockets  of  p; 

'"Illation,  am 

'"»gs-     The 

i"  the  pus. 

Case  rZ— ^ 

pockets  I 

tulierculc 

i-izzie  VV., 

Hurd  G,  April 

pain  in  the  rig] 

i'^ather  and  i: 

liistory  of  Jierec 

'"Jl't'  has  alwa 


TLBEHCULOUS   VLKVnisy. 


'jr> 


-ted  as  latent  and  oln-onic/d t.;;;'?'"''  '''r'"''^-'  ''-•.- 

-'i'i>-'ative  disease,  of  a  n,ol    "       '"'  '""'''  "'^--^neand 
;;'"  ;'.  v-y  rapid  course.     ^^7  '■''"'   "'"^  '"-'•  ''"^ 
'-d-sease  attacked  a  youn.  ]      ,/,"""""=  '•^'''-kable  case 
'^^•^'.■-V-'^  set  in  abn,ptrv\        7JT'''"'r^^-''^-.iiy 
'!•;  «f  •       On  adn,issioi   tC'^.^''   j""'  —  I'ain  i„ 
«Kie,  /eebJe  breathin.    but     !  ''"'"'^'^  '"   ^he  ri-d.t 

l%«ieaiexanWnatio„;:b;^r,rj-?  features  about:)!: 
^'"-"^;-  onbe  case,  and  n  ,  .7  '"^  ""^^'■^-■"  -^  'o 
7'"-";'"'-      ^V^ithin  a   few    b      '  ''''"'"^  ^  -vend 

^•'-•"-  ti.at  suppuration  n.ust  b  T'         '''""''   ''  «^^"'ed   so 

^^';:  -^"--i   to  operatr  lS:;;f  7;'-'  J^-  ilalsted 
collection  of  p..,,  ,,.,,^.  ^  -'^  of   f,„di„,. 

"-•y-ected  in  tlu.ee  differe,      i    ""=''  ^'"'•""•-^  ^^ 'i'- 

■f^^t  five  weeks  after  tbe  oust    :;'',?'  ^^"^''  ^-^  place 
"'-rations  were  present  tbro    d,    !,     ''.'^-     ^^^'''-kable 
I--t«of  pus  between  tbe      ?  ^   /  "  "='''  ^"-'-' -tL 
'""'ation,  and  an  extensive  ac    1   ''       ''""'  "'^  ^'"--^  ^^'-'cu- 
.'""f  •      ^i^'-  tubercle  baci  li        .'"f  ""^  '"'^--'osis  of  tbe 

'"^'^--;- -""^>etaiisoftb::r::i'--""-ers 
^™'^/^'>'-''^tb,?so^::::;:;,^.'-'-vasadnd^ 

'"■""  '"  ^'-e  riobt  «ide.  '"'"i''"''"ng:  of  chills,  fever,  and 

i^"tberand,notherlivin,.,„j„,., 

P^'^tctly  healthy  .i,,.      rj,,^,,^^^ 


; 


20 


THE    SHATTUCK    LKCTUIiF. 


in  service  ;  lias  only  been  in  this  country  a  short  time.  Slic 
iind  eryisipehis  of  tlic  liead  and  hcv  some  months  ajro,  and 
has  not  ijeen  quite  so  well  since.  She  was  seen  bv  Dr. 
Salzer,  who  found  siums,  ho  thought,  of  efFusion  at  the 
right  Ijase,  with  high  fever,  and  he  ordered  her  removal  to 
the  hospital. 

Present  trouble  began,  she  says,  fourteen  days  ago  with 
pain  in  the  riglit  side  and  fever.  She  had  a  chill  about  six 
o'clock,  and  a  had  a  sweat  at  night.  The  pain  was  of  a 
dnl!  character,  and  much  aggravated  on  drawing  a  deep 
breath.  There  was  no  cough.  The  fever,  pain  in  tiic 
side,  and  sweating  have  been  the  chief  symptoms  throutihout 
her  illness.  She  has  been  unable  to  work  since  its  onset. 
The  appetite  is  poor,  and  she  has  lost  considerably  in 
weight. 

April  8th.  Present  condition.  —  Small  framed,  well 
nourished  young  woman.  Lips  and  mucous  membranes  of 
a  good  color;  tongue  slightly  coated.  Temperature  on 
.idmission  was  101°;  this  morning,  at  10  A.  M.,  it  wa.s 
102.5°  ;  pulse  88  ;  respirations  28.  Chest  is  well  formed  ; 
good  costal  angle;  both  sides  expand  well,  the  right  mucii 
less  than  the  left. 

On  percussion  there  is  flatness  on  the  right  side  from  the 
fourth  interspace  in  parasternal  line ;  from  the  fifth  rih 
in  manuuillary  line  ;  from  the  sixth  in  anterior  axillary  line. 
At  the  back  there  is  flatness  below  the  angle  of  the  scapula. 
The  breath  sounds  are  clear  in  the  infra-chivicular  region, 
and  as  low  as  the  nipple.  Below  this,  behind  and  in  front 
they  are  feeble,  though  clear.  Behind,  over  the  flat  areas, 
respiration  is  feeble  and  distant.  The  vocal  fremitus  is 
absent  over  the  flat  areas.  There  seems  to  be  a  sli^dit 
movalde  dulness  at  the  level  of  the  nipple  in  front.  The 
cardiac  impulse  is  in  the  fourth  interspace  in  normal  position. 
The  sounds  are  clear,  and  of  normal  relative  intensity. 
The  abdomen  is  negative.      The  liver  dulness  reaches  to 


the  cos 
is  no  () 
acid,    ] 
the  casi 
tory  nei 
axillary 
range  d 
sometiin 
heavy  ti\ 
On  th 
regular, 
fjniet.     ] 
side  of  t 
pntion  th 
idarJy  at 
of  the  foil 
at  the  fou 
nipple.     ' 
horder  of 
in  the  nfp 
the   line    ( 
difficult  to 
front,  is  to 
flatness   ha 
entrance, 
tliei'e  are  fii 
by  cougliin- 
outward. 

An  explo 
tlie  eighth  8] 
■'  negative  n 


TUnEKCULOUS    I'LEUmsr. 


•  27 

tne  costal  mim'in  •  thn  i.     i 

""'■■''2».  n„  !,,,,'.,,,,„ '\^ ;;;;;•■-' w..vdw. 

••""""■7  line.  I„„  „„,|,i„„  „„,    V'"!"'  r'""°  '"  "'«  ".i.on,,,. 

"■■"«  i"S  .1.0  „ex.  Tvee     ,  "•  •    "'"  ' "'"'<""' 

soineti.nod  l„  1040  „,  „,„     """  '"'y  "'■osnl^.r,  ,e»clii„., 

heavy  ,„.c,,„  „,  „,V|„,  •     *"°  ''"J  oliilly  fe,.|i„g,  „„,, 

1-f.     Patient  lies  Jnn  wl.t  ^     "'"';  ''T'''''''^-  nre 
-'^  of  n.o  chest  nK>vc.  fj      "/>' "  ''^^''^  ^"^      '^''^  'oft 

l^'-   ^'-c  is  „.eat  ten.Ie..ne;s  ZZ'T''   ''''    '•"'" 
"'«'-Jy  at  t|,e  third  rUrUt  ;„.„  °  sternnin,  partic 

"^  ^''e  fou,-th  costa,  c:'.;!,  r^^'^  "'""  "  ''^  "^••""'  -^' 
'^:  the  fo.„.th  space  at  the  s^ei-nufn  .'r„:'  '"'T"  '"•^'"'^ 
"■PpJe.  The  flatness  extends  nc  n'  7  '  ''  ""■""^^''  ^''^ 
'•"'•''^■-  of  the  live.-  is  no     "       if  '''""""•     ^^ower 

f''«  "ne  of  flatness  is  clear  \!i  ," 'fl^"''''f''>"  above 
''■•ffi'H.lt  to  hear.  V..cal  fi-e  .  i  '  7  ^'''''^'  ^"^^^''"*'  ""cl 
'■-t,  is  to  he  felt  in       0  :      r  "  "'«  P-^ticall,  absent  in 

«''t-s  has  not  .natenall':  :.,i;  '^  ''^'  ^''^  '•-  ^f 
entrance.     On  auscultatio,;  "  °"'   ^''''^   ""^^'^    «" 

f''<^''e  are  fine,  nioist  roils  "  'TP'-oaches   this    li„e, 

'I  negative  result.  *  "^  scapula,  but  with 

"«'l.y.     There  „,„„..;:"    ;  ""  ">'"""' ^  t'-ngue  w., 

■«-"^.^..^nhe„e™i:;;:~-:;;!:n.: 


/.  i 


28 


THE    SHATTUCK    LKCrUUK, 


fourth  iiiteia|iaccs.     Tlic  Mood  count   <,nive  over  5,000,000 
red  to  till!  cubic  nun.,  and  1«,000  wliito  corpuscles. 

It  8ecinc<l  evident  tliat  tliere  was  supnurntion  yoing  on  in 
the  chcft,  and  it  was  thought  most  lilu'ly  to  he  an  empyema, 
l)()i>sihiy  diaphragmatic.  The  possibility  also  oF  a  sub- 
[)lirenic  abscess  was  considered,  tliougli  this  did  not  seem  to 
be  very  likely,  as  the  liver  was  not  depressed.  The  points 
which  made  the  case  somewhat  dubious  were  the  extent  of 
dulness  and  signs  of  cinision  without  marked  dislocation  of 
the  heart  apex,  and  without  anything  like  a  typical  line  of 
dulness  and  not  of  movable  character.  The  absence  of 
fluid  also,  on  a.spiration  with  a  good-sized  exploring  needle 
suggested  that  there  was  something  unusual. 

The  case  was  transferred  to  the  surgical  department,  and 
on  the  13th  Dr.  Ilalsted  operated. 

Lender  ether  nn  attempt  was  miido  to  find  the  abscess 
cavity  by  mea;.;-  ^  '  an  exploring  needle,  which  was  thru.^t 
into  the  righf  ;  ;  wi  the  chest  in  several  places,  where  dul- 
ness was  i;iai'k',;iJ,  Then  a  portion  of  the  fourth  rib  over 
the  painful  spot  wtts  excised,  and  only  a  small  pocket  of  pus 
found  ;  portions  of  the  sixth  and  of  the  eighth  ribs  were 
also  removed,  but  only  small  areas  of  suppuration  within 
the  pleura  were  seen.  The  wounds  were  stuffed  with  ifuuze, 
discharged  for  a  time  freely.  Tubercle  bacilli  were  extra- 
ordinarily al)undant  in  the  pus.  'J'he  patient  died  early  on 
the  morning  of  May  8th. 

Autopsy  (Dr.  Barker).  —  Body  somewhat  emaciated. 
Scars  of  the  incisions  mentioned  above,  and  two  of  them 
had  slight  sinuses.  On  making  the  preliminary  median 
incision  pus  oozed  from  beneath  the  skin  over  the  sternum. 
On  stripping  back  the  skin,  fistulous  sinuses  were  seen 
close  to  the  edge  of  the  sternum  in  the  second,  and  third, 
and  fourth  interspaces. 

Thorax  large  ;  costal  angle  wide.  Kight  pleural  cavity 
has  been  largely  obliterated,  the  visceral  being  intimately 


ndlierenf 

color,  tlii( 

ill  J)lace8 

diaphrai'ii 

'ind  appea 

face  of  the 

greenish  p 

necrotic  tis 

phragm,  c< 

there  is  a  1; 

has  infiltrat 

on  the  surf; 

abscesses  e 

the  boih'ea  c 

'■■'ce  of  the 

tlie  thickeiK 

from  a  marl 

•^Indded  vviti 

i^iey  and  tra 

On  the  ief 

I»leiu-a  there 

which  are  thi 

pleura  is  not 

somewhat  cnl 

with   tubercle 

miliary  tuber( 

tubercle  on  or 

enlarged  and 

miliary  and  si 

throughout  b( 

iii'e  reddened, 

•111(1  yellowish 

Iji-'iiie   of  the 

studded  with  t 

Jown,  and  the: 


Vixam/ixmMi: 


TunKiirrr.oi'H  i'r,Kui{r.sv 


20 


"'ll'erent  to  tlie  cnsUil  ,,le.,ra  •  b.,Jl.   I„ 

>"  places  fwilv  2  cm...  in  tl,i,.lo.n  7  "'^''  '*'^*''  "  '« 

""•'  ■"'l'l"~  ".0  pent....e  1:    o         ' "l      ■  "  '"■■''''"•"""' 
face  „f  ,he  ,,leu.,i  t  .c.v  ..-o  .  '''"pl"-a^'.n,..io  «,„- 

..ec-otic  tissue.     I„  i\.L   Zf  "'    ''  "'"  ''■"^'''  "'"' 

■•>''«ccvs.se8  exist  alo„.  ti.e  8„ino  ?  ''  '>'t'a-,,l.u.al 

"-  bodies  or  .,.e  ve.^eb. :.  '''He'.::.  ':,"  ^""'"  ■^''^"'">' 

-''^<>^<' vviu.  a  ,..i„,e  X   :  ;;,^ ;;  !"'>^ 

^'•ey  and  transJucent  sub-n..l,ary    t„be.-cle8, 

H^"" 'iwt'l:;;';:':::::  r  """°^'°""  -"  ^-« "•« 

»'-'.  are  .l.icW,  «         „'  ,,  "I  X:",::  ■"•"»■>■  ""-olc, 
'""."Vl,,,,  o„lar-cd   .Icc^^r  ,  "■"""'''"'  "''^...1.  „ro 

■";-'oo„„„„|„„fl„.„,.:,;•;.j;--^™.l...^^ 

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."ii»7  »n.i  .ub.„;ii,„;' :,  ":,r  ;,•  "■" "™°'"» '"""^ 

■remldoacl,  and  i„  »„L  ,1,  "e     !,.      ■""'  '"•"''"  l'»"=''=» 
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Sciences 
Corporation 


23  WEST  MAIN  STilEET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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30 


THE    SHATTUCK   LECTURE. 


Tlie  mesenteric  glands  are  somewliat  enlnrrred  and  hypenf- 
nnic.  Tliere  are  also  pale  yellow  areas.  The  glands  alonn; 
the  aorta  are  enlarged,  anc.  many  of  them  casuous.  The 
glands  along  thoracic  aorta  are  also  enlarged  and  caseous. 
The  cover-slips  from  the  pus  in  the  pleura  show  large 
nnnihers  of  tubercle  bacilli.  Agar  Esniarch's  t-ibes,  made 
from  the  pleural  pus,  spleen,  liver  and  kidneys,  remain 
sterile. 

2.     Sub-acute  and  chronic  Ttibercnions  Pleurisies, 
There  are  two  groups  of  cases,   with  effusion,  and  the 

chronic   adhesive  form,  the  former  being  by  far  the  most 

numerous. 

(a)      ]l  ith  sero-fibrlnous  effadon. 
The  process  may  be  primary,  or,  at  any  rate,  most  exten- 
sive in  the  pleura,  or  secondary,  to  manifiSst  tuberculosis  of 
the  lungs. 

The  primary  constitute  an  extremely  important  division 
of  the  tuberculous  pleurisies,  and  here  may  be  reckoned  a  not 
mconsiderable  number  of  all  the  cases  of  the  insidious  form. 
The  true  character  of  the  disease  is  frequently  overlookc(i, 
and  indeed  for  a  long  time  there  may  be  nothing  positive  on 
which  to  base  a  diagnosis.  Though  we  speak  of  the  disease 
as  primary  in  the  pleura,  in  almost  every  ii  stance  there  are 
tuberculous  foci  in  the  lungs  or  in  the  bronchial  glands,  oi 
the  process  has  extended  from  the  peritoneum.  Freqiientlv 
the  cases  are  admitted  to  hospital  with  acute  manifestations, 
but  with  advanced  pleural  lesions,  evidently  of  long  standing, 
iinto-dating  the  pulmonary  tuberculosis.  The  following  arc 
illustrative  cases  : 

Case  VIZ. — Bilateral  luhe.rculous  pleurisy ;  acute  tuher- 

culosis. 

Henry  W.,  aged  43,  admitted  July  29th,  1891.     Katlier 


more  tli 

fir.d  was 

nncl  sho 

Ijegan  al 

shortnesi 

rigors,  a 

very  JittJ 

does  not ( 

on  admisi 

i2»  J  resj 

clear,  nc 

TJie  CO! 

on  (he  Jei 

liglit  side 

tlieie  was 

"ote  to  Jov 

to  the  fourt 

Defective   ; 

^eliind,  ant 

numerous  i 

distant  tubii 

fit  the  left 

base,   with 

pected  at  b( 

liglit  intersp 

etfusioji  foui 

tlie  eighth  U 

(li;eniorrJiao-i 

baciiJi.     The 

He  became  t 

fi'iger  tip6  dei 

li>0,  and  Jie  d 

Autopsy    ( 

well-nouii'xhed 
line  93  cm. 


I'lore  than  a  year  .,  . 

^nd  .hortucss  of  breath.  He  7.7''"'"'"°  "^  '^""«''. 
l^egan  aboK  four  .eeka  a^o  e  "  "  '"""'  ^'"•"^'^ 
«!">'•'"-  o:  breath,  h  fu J  2t f'r''  '''''''' ^^^^^ 
'•^Sov.,  and  had  fdt  ve. y  weal  H  ^  '""''  ^''<^"'''  »» 
ve-T  iiuie  expectoration'  no  ,ai„  't  \  '  """'  ^""^^''' 
d«e«  nut  think  that  be  ha«  Jo.    '  "  ' '  f ""  "^  ^'''-     ^^^ 

->  adnu««ion  was  102^^ ;    he   oi?^  •"  ""'''''■     '^^^'^P^-^ture 
1^^«.-  .-expirations  36.     T,  «"'"'"=  r'"*"°  ^^'^' '  P"'^e 

«"'''^^eftt,.an:::^;;;:^^:;;rr'""«''^^-i-ie.nore 

;;^^''^  -'e  at  the  apex,  and  to  'he  ^7'";  ".'^^"^  ^"  ^''« 
^''--  "as  in.p,.ired  resonance  On  '  'I  '  '^'^'""  "'"■^•'' 
"ote  to  Jower  border  of  second  "rib         ,  '"  ''^'-'  ''  '^J^'"- 

''^  t'.e  fourth,  and  fronuhefo"!;'''""^  ''•"'»  ^'^  -^^nd 
^ef-tive   resonance  over  X  'e  /";"'''  ''^''^  '^  «''^"-- 
l-ehind,  and  flatness  at  ti.e  b.se        '"    .  T'"''  "^'  '^''  ^'^"S 
"."'—  raJes  at  the  apex  ""l      "       •-     ' '""°  ^''^'-^  "- 
d-atant  tubular  breatiun-'     L  ea  l  ^'^^'^^'i''-!"^'  «n^J  behind 
;''  '''«  J^^'  base.     On  The  H-  1  f    T",       "''  "'"'"«'  ''*>««"' 
t^-e,   with  distant  tuOuh^  bf    ,r      ''"'"^  '«  «''^"-«  "t  the 
l-'^cl  at  both  bases,  .^d  J    "  l'"^-  •    ^^-'^  -as  sus- 
r;gl.t  interspace  behind,  al;:;,,"^^''''^^^  ""  ^'-  eighth 
effusion  found.     On  the     ,1  ;"""""' "^^"^'•""'•^''"<Wc 

i'«3n>orrhagic)   ren.oied        I  !       '"^  '"^    *«^^'  ^'^-  »f  «uid 
-i'ii-     The  ten.peratur;  w-l  hi.T"^'  '""'"'"'^    '"^^-'^^^ 
He  became  delirious   had  °  '    ''""^  ^^^°  '"  1^*°- 

f  ■'.-  tips  cieveloped  'a    'tS 'T''<^'  ^'—  of  ;,, 
^^0.  and  he  died  on  Ihe  n^t^''''  '"-''  -'^eebled, 

;"^W    (Dr.    Counciinn^?    i    '^'■""■^^'''• 
;veJI-"our[shed  „,a„;  circumfiri*         '>'"'     ^^^^^^-deveJoped, 
line  1)3  crn.  «'rcumference  of  the  thorax  in  nipplj 


I    i 


32 


THE   SHATTUCK   LECTUUE. 


i 


■^  ■,. '  I 


Left  pknirnl  cavity  partially  oblitcrateu  by  old  adhesions, 
especially  at  tlio  apex  and  posteriorly.  The  remainder  ot' 
tlie  cavity  filled  wi  h  about  300  cc.  of  turbid,  yellow  serum 
with  flakes  of  fibrin.  Uoth  layers  of  tlie  pleura  much 
thickened  by  a  new  grey  vascular  tissue,  and  covered  with 
a  gelatinous  fibrin.  There  are  many  opacpie  white  nodules 
beneath  the  membranes,  and  the  thickening  is  marked. 
The  layers  can  be  peeled  off  as  a  continuous  membrane, 
and  beneaih  thei'i  can  be  oeen  opaque  yellow  and  grey 
miliary  tubercles.  The  right  pleural  cavity  presented  old 
adhesions  only  at  the  base,  and  it  contained  3;")0  cc.  of  sero- 
fibrinous fluid,  the  surfaces  covered  with  fresh  grey  fibrin  ; 
the  {)leiu'a  and  the  membranes  slightly  thickened. 

The  pericardium  was  smooth  ;  heart  ijresented  nothing 
abnormal. 

Lungs. — At  the  apex  of  the  left  lung  there  is  an  irreguliir 
cavity  measuring  3  by  o  cm.,  the  tissue  about  it  in  a  coii- 
diiion  of  gelatinous  and  tuberculous  pneumonia.  There 
are  clusters  of  tubercles  and  miliary  granulations  scattered 
throughout  the  rest  of  liie  lung.  The  right  lung  presents 
a  few  scattered  miliary  tubercles  without  any  very  huge 
areas  of  consolidation. 

A  i'ew  fine  miliary  tubercles  were  found  in  the  kidneys ; 
mesenteric  glands  presented  a  few  small  tubercles. 

The  condition  of  the  pleura  here  ante-dated  evidently  the 
more  acute  onset  of  his  final  illness,  and  he  was  prohahlv 
the  subject  of  a  latent  tuberculous  pleurisy,  followed  in-  a 
general  infecfioii. 

Case    VIII. — Chronic  tuberculous  pleurisy  loith   elja- 

sion. 

E.  .S.,  male,  aged  31,  colored,  admitted  January  l:>th, 
18S)L  complaining  of  cough,  pain  in  the  right  side,  iiiid 
dyspna'a.  He  has  had  cough  at  intervals  for  a  year-  no 
lucmorrhage.     About  Christmas  of  last  year  he  uot  vcrv 


nuich    \ 

sweats, 

and  pci-i 

He  is 

finger  ti 

respirati 

the  secoi 

side.      I] 

inovcd. 

bo.-der  ol 

at  the  b; 

L'4o,  Mui 

asj)irated 

The  c|)ufj 

until  the 

nioderate 

extent.      ' 

IJreatli   so 

present  on 

still  very  i: 

rules.     Th 

bronchitis, 

tubciT'lc'S. 

peratiu-e  kc 

i3<l,  when  h 

Aiito])sy 

extent;  fin 

of  slightly 

leatheiy,  d; 
I'uver  lobe  j) 
fiiul  costal  I 
J^'i.^'Iit  limy 
grey  tiibercl 
Cfivity  about 
u-'denintous. 


:lTt>- 


TL-nEKCLLOUS    PLKUIM8V.  oo 

He  IS  well  iiDurislipd  •   f.mn   v 

"i"vcd.      After  ..8..;r.,f;       ,.  '    ^"^  "^O  "f  fluid  re- 

'.-io.or,,,i:jiZ';;r;:  ::iv:;vr 

»'  'lie  l«.-c.     TI,o  ton.nn,.  ''"«  '"">  «»l"Kd 

uiHi     UO    1   or    PniKrli  ^^l 

as])irated  n-ain  on  the  9q,l        ,  T  '"^  '"'^"■"^  ^v'"* 

riM  ^  "^  ''^^  «nd  one  J  ho  <>f'  «   •  i 

il.e.,>„t.„,,s  exannnod  renc..Uodh.       •!<  '■"""^•'•'• 

""fi'  fJ'o    l«t  of  Fel„u.uv        I     ^',"     '  "^^^■■'^•^'<-' ■•-.dr., 
n>oderaten„n,be,.T  :«.;,;:  :7'      '"'"'    ^^^^    ^-<'   i" 

-'e"^.     Ven.  .narked    LwJ;       •"'""■''"'"^ '' ''">• 
B.-catl,   sounds   were  cl  ^.I      'T''""  ""''"' ''"^^ -■''^"• 

P-ent  on  the  left     de  ^o  fl     I        't "  "'^ '"  ^■""'"^-  -"* 
^'"•11  verv  .narked    r,,/      ^'T'  "''"=''  "'^  ''"'"^•-  -''^ 

Penuure  kept  high  until  the  •    '/       i  ''"'"  '  '''^'  '^■"'- 

^'1,  when  he  died.  '  ^'" ''-^^"•""'  '''<-""  ^'  ."'SO  ,„  „,, 

Autopsv  (abstrnef^        T:   i^     i 
0«0,„  ;   ,i;„  .  :,'„-""  !•'<=""   -"--"  "VC-  o,„;,.„ 

lc„  „„l,a,-^  ,„ke,dc»  sca.,0,.0,1  ,l,„,„j,l,„,;, 


I , 


'n 


i 


1 1 


84 


THE    SHATTUCK   LECTt-RK. 


the  lung.  Small  nicer  in  the  left  vocal  cord.  No  tubercles 
in  tlie  liver  or  spleen  ;  one  small  tuberculous  ulcer  in  the 
intestines. 

]More  commonly  the  pleurisy  sets  in  insidiously,  and  is 
the  most  prominent  feature  in  the  ease.  There  may  be  no 
suggestions  of  tuberculosis,  but  in  some  instances  the  his- 
tory of  a  previous  attack,  or  of  haunoptysis,  may  arouse 
8usj)ieion8.  After  asjiiration  the  Huid  re-accumulates,  and 
repeated  tappings  may  be  necessary.  The  patient  regains 
a  certain  measure  of  health,  with  greatly  thickened  pleural 
membranes,  and  persistence  of  tiie  dulness  on  the  atfected 
side.  When  these  cases  are  carefully  followed,  a  certain 
number  of  them  develop  unmistakable  pulmonary  tuber- 
culosis, or  they  die  of  a  general  infection.  The  following- 
illustrative  cases  are  of  interest,  from  tiie  fact  tiiat  they 
were  inider  observation  for  loii'xr  periods  than  is  usual  in 
hospital  practice. 

(y((se  /A'.  —  Uoiiyh  and  /icenwptysis  a  yea)' before  ;  (jrad- 
ital  onset  of  the  effdsion;  repented  attpirations: 
tubercle  bacilli  found  in  the  exudate;  tmbsequent 
developmoit  of  pulmonary  luberculusis. 

Christian  T.,  aged  39,  German,  admitted  September 
25th,  ](S(^1).  Patient  is  a  large,  well  built,  nuiscular  man, 
very  well  nourished,  with  thick  panniculus  adiposis.  Willi 
the  exception  of  measles  as  a  child,  chills  and  fever  in  Ger- 
many, and  a  ciiancre  with  mild  secondaries  in  1884,  he  has 
enjoyed  excellent  health.  Xo  history  of  [)ulmonary  trouble 
in  his  family.  His  wife  died  of  consumption  four  years  a'^o. 
He  was  very  well  and  strong  until  al)Out  a  year  ago,  wlien 
he  had  cough  with  much  expectoration,  and  on  one  occasion 
he  spat  up  a  mouthful  of  blood.  In  January,  1889,  he  lost 
in  weight,  and  for  the  first  time  began  to  be  short  of  breath. 
He  had  no  pain,  and  was  able  to  be  at  work,  but  on  any 


exertion 
been  hiti 
does  not 
admissior 
"■eiglit  ai 
The  chest 
is  no   spe 
fuller  than 
expands  V( 
in  the  fifti 
"ipple  lim 
either  side, 
hiller    thai 
fremitus  oi 
itnd  there  i 
anteriorly  i 
Jh'catli  sou 
except   in 
ttihularand 
and  loud, 
moved.     Oi 
tlie  same,  an 
It  was  more 
-'"i  ounces, 
general  cond 
and  about  tin 
t'le  11th  he  v 
Jiawn.     He 
lent  expecton 
successive  da_) 
liistory  of  an  ; 
''•lised  a  suspi 
'liere  was  not) 
"ifl  it  was  m 
nearly  three  m 
established,  thi 
3 


«^^^^^^l^^i:i^^li^^Mtli^ 


i^^i^^MfiiS^ 


TUUKKCLLOUS   VLKVlilSY. 


exertion  l.o  becn.ne  breathless    ,„,,   , 

^'-  not  think  tl...;  he  ,;::  I..':;  ''  ''^-^^  «-''^-  -'.-er.      He 
achnisMon  was  .%o       t|„>  .    i-       ?  ,    '^'' '   ^'^'"l'^^'""^ '"-e  on 

"■^'•^'''t  about  ICO  pounds  r,  •'-*'" ''"''^''^'''''^'''''''; 
'PI       1         .  I'^inius ,   pulse   is   7-> .   t  . 

n.e  ehest  i«  lar^e,  well  forned  On  '  T^'''  ''  ^'''^■•"'• 
'«  "o  ^^Pecial  difference,  no, '  'l  ,  ?  ^""'  ^'"''^^'"^  ^''e'-e 
A.ller  than  the  left.  Whe  ,  '.  "^"^  ^  ''^'''^  -''«  looks 
expan.I.  very  .li„|.„„      '^    ''"  ''"'^^  '■'  ^'^ep  breath  the  ri-d.t 

^'! ''i-^'>  ^--^,'ce,  bi:::;:  i;77  ;-^^^^ 

"'I'P'«  ''"e.       The  intercostal  "'^  ""'«'^«  ^''^ 

eit'-r  side.      F.,,...  behh  d    t^^     •'";'"   "'"  "'^^   "''^'^^^   on 
'"''-    tl.an   the  left  ;t::^^^^^ 

f'e.ni'us  on   the  ri^ht  side    .''''"    "'"''   '^  ''^'"^^"^0   of 
"-'  "-e  i«  ab.oi:te  du    e^    r^  'T  '"'"""  ^''^  ^''--'^^ 
-teriorl,  it  extends    to      "  IftV    ,  '"'"'"^'^  ^'""■"'  ^'^ 
i5.-eath  sonn,Is   are  feeble   -ukI     r    "       '  "'  ^''^  «''-'^"""'- 
--P'  i"    th.  lower  in  L     Lit   "       "'   '"  '"'"''^  «'^^' 

:'-'•  ^"•''oH.vst"fo:;i,:.ri^t:'"''^"--- 

I'e  ^sune,  and  30  ounces  were  ..,; '  •"  f  ^'''  l"-"«f'"«ally 
"  --  "'ore  turbid.  On  tie  ifh ^  ''^'■"^'"-  '^''"'^  ^i"- 
2.^  ounces.      Cover  slips  „nd  c  ""'  "^'"'"^^^  "^-"■"  >• 

J,-"o.al  condition  all  th L  "L  '"  "?'''  "e^-tive.  ^j; 
-''  «'-"t  the  ward,  a  d  th  tenn"  ""  '""  '^^  "'^  "i' 
f  ^^^''  '-  was  a,ain  tap  eV  J'aT"  ""  ""'•'"'^'-  ^^ 
J'-'nvn.  fie  had  a  very  s  i  It  e  ■  T'''  '^'  ^"'^^  "■"t'- 
'^^  -pectoration,  w'.fch  w  !'^  '"'!''  '""^'''  — l'"'- 
;"--ive  days  wilhou  di^::^:;:'?^^.;!?''^  ^or  seventeen 
'"«tory  of  an  attack  a  year  "J       f  "     ^■^'"'"'=''  ^J- 

'•'"■^ed  a  suspicion  thi  til  '"""''  ^'"^  '"«'"oi.tysi. 

"-■0  was  nothingwl     etr^T  ''''''  ''  '"^^-^"-' 
-'  it  was  not  until  t,^^'^  "\^" '''''^  ^^^^^^^ 
"--•ly  three  weeks,  and  h      con  1  ""'"'  "''^^'•^''^'""    f-' 


if   I 


l'^ 


Elisspi^'~-*v^¥j^:ii 


.' 

I 

! 

i 

i! 

3(5 


THE    SHATTUCK    LECTUlfK. 


Oil  till!  18tli  lie  wa.s  iispiratod  and  ;»2  ounces  wore  witli- 
drawii,  and  tlio  note   liocanic   clear   as   low  as  tlio    nijiple. 
On   "J7lli    11)  ounces   were  removed.       On    November  7tli 
tlie  note  reads:    ''The  right  lung  is  fairly  resonant  to  the 
fciirtii  rib,  and  in  axilla  to  eighth,  posteriorly  to  middle  of 
scapula."     'riie  fluid   again   accumulated,  and  on  the  l(!tii 
2<S  fluid  ounces  of  a  greenish  yellow,  slightly  turbid  fluid 
were  removed,  in  which  tubercle  bacilli  were  found   by  two 
separate  observers  on   the  Kith  and    ITtli.     'I'lie   measure- 
ments on   the  right  side,  li)  inches,  on  the  left  18^  inches. 
On  the    llth   he   was   a8[)irated   for  the   eighth   time,   and 
32  ounces  of  fluid  removed,  of  the   same  clear  character. 
The   note  was  resonant  to  the  fifth  rib  and  behind  to  the 
middle  of  the  scapula.      In  these  regions  the  breath  sounds 
were  loud  and  free  from  rales.      Cultures  from  this  fluid  re- 
mained negative,  and  no  bacilli  were  found.      Patient  gained 
in  weight,  lost  the  cough  entirely,  and  was  only  short  of 
breath   when   walking   fast.       Apjietite  good;    sleeps  well. 
lie  decided  to  go  out,  and  was  discharged   December  IHtli. 
At  the  time  of  his  discharge  resonance  was  clear  and  a  little 
high-pitched  on  the  right  side  to  the  third  rib  in  front ;  below 
this  there  was  absolute  flatness.      Uehind  it  is  high-pitched  to 
spine  of  scapula,  and  below  the  note  is  flat, ;  left  lung  clear. 
Breath  sounds   are   normal.      This  patient  was  under  my 
observation  on  and  off  in  the  dispensary  for  many  months, 
and  at  Hist  seemed  to  do  well.      Subsequently  he  was  lost 
si'rht  of,  but  I  heard  that  he  had  developed  extensive  tuber- 
culous  disease  of  the  lungs. 

Case  X. —  Covf/h  for  several  years,  hut  good  health: 
(jradually  shortness  of  breath;  rlyht-sided  phur<d 
effusion;  repented  aspiration;  great  improvement; 
discharge  ;  subse<pient  detection  of  bacilli  in 
sputum;    development   of  pulmo7iary  luberculosin. 

Henry  H.,  stevedore,  aged  30,  admitted  June  13th,  1889, 


coniplai, 

died  of 

been  an 

weJI  non 

(""".irli  foi 

He  has  b 

"f  idl  ...n; 

'idl,  and  i 

beat  is  in 

line.     Til, 

expansion 

on  tho  JL'ff 

ii  dull  note 

i"".!?,  and  I 

'I'lic  left  si 

lessened,  bi; 

side.      J}iei 

^VIiisporc(f 

I'-xploratory 

purulent  i\n\ 

litres  of  f|„i( 

o'l  the  1 7tli  ( 

nspiratcd  af.-i 

was  greenish 

i'e-iiccuniulat( 

li'th  with  a  V 

■1  withdrawal 

ilrawal  of  27 

front  perciissii 

(luliiess  from  t 

middle  of  (he 

tlie  Mxilla,  (lisi 

llie  8tli  of  Ji,|_, 

cliaiged.      The 

just  below  the  u 


TUnK«CLXOU8   PLKVUISY. 


.37 


-^ - '•" ti.o fim. into,.,,;  rv"'^""''"" ' ''^ "1- 

<'-^l'"nsK,„  on  the  n,|.t  «i,,e  fs  s.  '  '■'^''"  2^'  '"^''"-'«  = 

Je^'«enod,  Inu  on  saying  99  it  is  ,1/     . •  T'"''"'  '^  ^■•-■'••>-  "'"^•'« 

^\l"q)orod  voice  over  ,!.«  dul  •         "'  ''"'''-■"'^^'  '""^'■|''e. 

T""'"'^  «"'J-      Tl.e  foJJowin.  c        ;;""''^^''  ^••-"''"-'  «-o- 

-  t'-  1 7,1.  „.e  condition  wa      e  "''"f'","  ^"«  -"'•^  -<! 
-'l"-^-J  '.«-.in,  and  32  ounce    ^''-f  "  '^'''•'•'^-      ^'«  -as 
-«  .^-eni.).  ,eJIo.v,  with  ^     /    ''  'T""-'^"     '^'''i^  fl"id 
>e-aecun>ulated  rapidly,  ,„,,  ,;«?,       '""'''"''^«-     '^'''0  rtuid 
^•'"' "■'■'''  a  withdraw'    of  32  ;      '"'•"■'^^^^  •''^^-■"   <>"   the 
•^  ^^"''^'--l  of  29  ounces    .nd""'"'';  ""  ""  '''^"  -^<'  -■^'' 
^•■•''  "'■  ^^7  ounces.     Ont       20tV       ""'"''■'^'--''- 
••O'-t  pero„s.ion  is  now  dear  to  W      T  "'!''  ""''''  ^'"'^  '» 

J"''H-  r.-om  this  point  dow      p  :  'r'  ''  ^'''^  "'Pi'io; 

-  --•"a,  distant  breath  s,n  ndfo  ''",  ^'•■^^='^''»^'  -'^'-  i„ 
"'^  «th  of  ,hny  he  h.d  il  '''■  ""  •'""  area.      JW 

-'^^'"-'-^^pp'e,anj;;;;:e::,':j^;;;!-n-pace, 

"laiKecl  h-iction  sounds 


£:  j;i 


[«• 


38 


TlIK    8IIATTUCK    LKCTUllK. 


in  the  loft  mniiiiiiary  region  and  in  the  acnpiihir  region 
Ijchind.  'I'iie  cover  slips  luid  cultures  made  hy  Dr.  AI)hott 
from  the  tluid  were  negative.  When  he  entered  the  hos- 
pital the  sputum  was  abundant,  sero-purnlent,  and  was 
examined  repeatedly  with  negative  results.  Sidiscquently 
his  cough  lessened  and  ex[)ectoration  was  more  scanty, 
thicker,  and  greyish  yellow  in  color.  At  no  time  did  the 
temperature  rise  above  100^,  and  it  was  usually  between 
'J,S^  and  l»y^. 

He  left  the  hospital  with  a  diagnosis  of  pleurisy  witli 
eil'usion,  and  though  there  was  a  suspicion,  based  chiefly 
upon  the  fact  that  he  had  had  a  cough  for  so  long,  the 
diagnosis  of  tuberculosis  could  not  be  positively  made,  and 
he  looked  such  a  vigorous,  healthy  man  that  it  did  not  sccni 
likely.  lie  attended  in  the  dispensary,  where  I  saw  liiin 
rei)eatedly.  On  the  20th  of  July  it  was  noted  that  though 
the  apex  beat  was  just  below  the  nipple  in  normal  position, 
there  wiis  everywhere  defective  resonance  over  the  right 
side,  not  absolute  flatness,  and  everywhere  from  the  second 
rib  down  there  could  be  heard  a  loud,  leathery,  creaking 
friction.  lie  remained  in  very  good  condition,  though  the 
cough  still  persisted.  He  had  no  fever.  On  September 
lOth  tubercle  bacilli  were  found  in  his  expectoration.  The 
leathery,  creaking  friction  persisted,  and  the  defective  reso- 
nance on  the  left  side.  He  had  lost  somewhat  in  weigiit, 
and  the  cough  had  become  aggravated.  On  Se[)tenil»er 
4th,  18'J0,  I  made  the  following  note  :  There  is  marked 
depression  of  the  right  shoulder ;  shrinkage  of  the  right 
chest.  Heart  is  a  little  drawn  over ;  impulse  in  left  para- 
sternal line.  The  resonance  is  defective  above,  and  shiidi's 
to  dulness  below  the  level  of  the  fourth  rib.  The  tactile 
fremitus  is  felt  to  the  base.  At  the  right  apex  the  breath 
sounds  are  somewhat  feeble  ;  there  are  numerous  n\les  on 
coughing,  and  on  drawing  a  deep  breath  the  sounds  are 
amphoric.     Marked  cavernous  breathing  at  the  apex  behind, 


The  l,r 
l)afle. 
He  con 
On  the 
feet  svve 
more  co 
inspira^'i 
signs  at 
nfter  this 


r( 


fco.  ,W,||  „,  ,•„„„„,    .''    ""°  "'"  ■    "«  «lill  l..„k,  won  ;    ,1... 

-rc  c,„.„,,.,e,  •„'!:'".'"■ ™»l.-  '1.0  ,i.,„  ,:,„,; 

'"',.."...•..,. .„o..„ i. vow, '    , ■ ,™."" ■   f ;■ ,. 

•'"8.     A.,    il'rPll     90       n  "<"l  . 

»l<»ck-  ,i,„il,„.  ,„  ,1,0        "^„  •  „j''™  "'°'"l'»  a.-,.  1,0  |„„|  „;, 
'Vilii  fevor,  cliillv  looli,,.,,    ."         \      '     "S». -him-   24,1,, 

'""" 'I- -»".!,, „„„ „:;::„  ,: 'f ■■  ""f.- »« ,v„,.fco„ 

Joe,,  n,,pi,.„i„„,  „|,^„  ,,,„,    '' '"^'""'  •  '""■■"  "  i,lo,„  „„ 

«'»-'■"»  in.o  ".a„„„a  r  rM'  "'"  '"■'  "P«. 


!| 


PMJ 


i    I 


|i  M 


|"ii 


fll 


i 


t 


40 


TIIK    SIIATTUCK    LKCTITHK. 


cxtieiiicly  movable  nnil  iiscoihIh  wlieii  \w  sit.-'  up.  Hcliind 
it  readies  to  the  niiddio  of  tlic  scapula.  Dij^tunt,  tuliulm 
brcatliiiij,'  over  tlie  dull  reyion.  No  friction.  Souiuli)  on 
tlic  iij,dit  «i(lo  clear. 

Apex  boat  of  tlic  heart  not  palpal)le;  houikIk  cleai' 
Didiiess  in  the  sittinjf  posture  at  the  level  of  the  fourtii  rih  ; 
movable  dulncHs  very  marked.  The  temperature  lOP; 
the  cou,i,'li  is  better;  sputum  is  muco-punilent,  and  doc- 
not  contain  iiacilli.  On  the  Mth  the  temperature  Imd 
fallen  to  UH"^.  The  effusion  had  not  increased,  and  tiic 
movable  dulness  is  now  more  diUicult  to  obtain.  Tliou;;h 
there  were  a  few  r.'des  in  the  left  infra-clavicular 
space,  there  did  not  appear  to  be  sij^ns  of  any  cavitv. 
The  pleural  effusion  j^radually  diminished,  and  we 
wore  inclined  to  regard  the  case  as  one  of  simple 
pleurisy.  lie  still  had  cough,  with  streaked  nuicoid  anii 
yellowish  expectoration,  and  in  it,  on  the  18th,  well-char- 
acterized tubercle  bacilli  were  found.  He  improved  very 
much,  and  on  the  22d  decided  to  go  out.  On  the  left  side 
the  resonance  was  clear  to  the  sixth  ril).  There  were  suh- 
crepitant  rales  over  the  third  ril),  and  in  the  lower  axilla 
slight  friction  sounds.  There  was  dulness  in  the  infra- 
scapular  region,  diminisheil  tactile  fremitus,  and  feelile 
breath  sounds. 

This  man  was  lost  eight  of  until  February,  IS',}',],  of  ihe 
present  year,  when  he  applied  at  the  dispensary,  complain- 
ing of  cough  and  pains  in  the  chest,  and  diarrha'a.  lie 
has  kept  pretty  well  since  hfs  attack  in  188t>,  and  has  been 
at  work.  He  is  now  fairly  well  nourished.  He  has  very 
slight  ex[)cctoration,  and  none  could  be  obtained  lur 
examination.  There  is  rather  a  high-pitched  note  over 
both  apices  and  there  are  moist  nMee,  greatly  increased  by 
cou"hini'. 

The  effusion  in  these  cases  is  sero-fibrinous,  often  has  a 


green  isl 
ha'morrl 
Hacterln 
of  Chrisi 
itself. 

Sero-i 

piilniomii 

The   case 

iiosis  is   I 

plication 

The  insid 

infrequent 

shortness 

oi'iginal  di 

seemed  to 

with  recur, 

case.     Son 

mine  wliicli 

ing  case  ;    ( 

that  the  jilFi 


TlMiKiMirous    I-LKUIUSV. 


?:'■ 


if-lr.  "'''""'"'   ^^•-'^"'■-""i   in  tlu.cxu.laro 

'S<3r(»-/il.riM„„s    DlciirHv     -.„ 

f"' y  .nl,o..o  I,  ,;,:":,";'■'."";    '"    "•«    o„n„e    „f 

'■''"  ■■■■"-  «io   bv   „„    „  """■■■"  '"  '•'■'■■>■  ■""^•'•. 

'<"  '">">•■■«>  ..„„t  ,„„,  „,„  „,; '  '  I .'"  '1"^.  img  ,ii,c,,.c.. 

""'■""■•I  I"  Il,«  ,|,„  cri,.  inn  '••'""■"I""'-      I.    I,«, 

""'  -«•"".«  ex .i,::^,  ':::;,  - .  "r  "-"«■  -- 

«»«■     S>,„c,i,„e,  i,  i.  ,11^',,,;  """"I'  "f  cl,m„ici,y  „,  ,„„ 

77-. ^^^'!:r  ::,';:;::■ ""'!''''' - 

•''li«k"""-s  ii..ll,i„„  „f  |,B,.  r,,  .,,"•■'"'•   ""'>    'vo„k-„c..8. 
l'CM.„„i,e,  .110,1  ,„°,„;,„,,';,'  '"""'>■  '""""■.>••  l".-.l,e,.  ,!,.„  „,„, 

J'r''ur:':i:;',;,''f  ;;:f;';"",f  •  .-y"""  «-■ .i. 

P-.™.  illnc,  l,e,„„   .;",;"    "'  -^'l«™n  *....     Ilcr 

'"' -»".-i.:^;.M,t ;',:;:;';' i'"*-  «'■« 

(»ral,„,„  „v„  „;e|,,        ?  '  "'•'  ''"="  'l'"""g  ".Lick  sluN- 

s- de„,  „r  .,,„  J;,;:;!  ;;!:;;;;^ -'"-- »i.e  w  « „ 


I 


42 


THE    SHATTUCK    I.KCTUUK 


Present  condition. — She  is  eniiUMMtetl ;  much  more  so  than 
is  consistent  witli  ii  history  of  an  ilhiess  of  sucli  sliort  dura- 
tion. Tlie  tiiorax  is  Jong  and  narrow.  Tlie  clavicuhu-  de- 
pressions are  nuuked.  Tiio  exi>an8ion  is  more  marked  on 
tiie  left  than  on  the  riglit  side.  Briefly,  the  pliysioal  exam- 
ination gave — at  tiie  left  apex,  signs  of  an  extensive  cavitv. 
with  cracked  pot  sounds,  jind  am[)horic  l)reathing  ;  at  the 
rigiit  apex  tliere  were  indications  of  a  smaller  cavity,  be- 
hind, there  was  marked  didnees  in  tlic  supra-spinous  fossa', 
and  impaired  resonance  over  the  whole  of  the  riglit  side  hehtw 
the  spine  of  the  scapula,  with  feeble  breathing,  and  rales 
only  on  full  inspiration.  Tiic  abdomen  was  swollen  and 
tympanitic;   no  signs  of  effusion. 

The  patient  had  an  irregular,  hectic  fever ;  her  pulse  was 
very  rapid;   she  failed  progressively,  and  died  on  the  l.Stl.. 

Postmortem  (by  Dr.  Flexner.  Abstract) .  —  The  [leri- 
cardium  is  adiir-ent  to  the  right  pleura,  but  is  itself  smooth 
on  both  of  its  layers.  The  right  lung  is  universally  adhe- 
rent ;  the  left  is  adherent  at  apes  and  in  places  behind. 
The  left  lung  presented  a  large,  irn-gular  cavity  at  the  apex, 
numerous  groups  of  miliary  tubercles  and  caseous  musses, 
with  small  cavities  in  the  middle  and  lower  lobes.  Where 
adherent,  the  pleura  is  not  specially  thickened. 

On  the  light  side  the  pleura  is  everywhere  adherent  ;  the 
entire  lung  is  much  reduced  in  volume,  and  measures  oiiiv 
12.,")  cm.  in  lengtii.  The  top  of  the  upper  lobe  is  occupied 
by  an  irvegtdar  cavity  lined  with  slate  colored  granuliitioii 
tissue.  Tiie  pleura  of  this  lung  is  enormously  thickened,  more 
particularly  the  costal  layer,  which  measures  D  mm.  on  the 
side,  and  about  11  mm.  on  the  diaphragm;  and  in  other 
places  it  is  at  least  2. .5  cm.  The  tiiickened  membrane  is 
uniforndy  yellowish  in  color,  and  shows  cheesy  masses. 
^.Vliere  the  visceral  and  costal  layers  are  not  adherent  tiiere 
is  fibrinous  exudate  on  both  surfaces,  which,  when  scraped 
off,  shows  tubercles  on  the  membranes. 


The  I 

TJiere  is 
tonea]  n] 


I  Iiave 

'ubereub 

I'lirident 

'*ii'>acuto 

effusion  is 

'•imount  of 

'hat  anion 

one  form  o 

mortem  frc 

'^'"'    effusi 

tiiberculosii 

there  ware 

to  an  acute 

of  tubcrcul( 

nrferio-scJer 

■■'ide  and  a 

instances  pn^ 

Our  clinic 

thorax,   of   v 

course,  d->  ... 

the  \{]  cases 

'erred  as  sooi: 

side,  there  vv; 

iiit,ther  in  five 

ciilosis ;  and  i 

'lie  I)ancrea8, 

sclerosis ;   f,„„. 

wliich  were  op, 

'ecily  wellorvc 
'"Stance  of  emj 


TUBKHCULOUS   TLKUiUSV. 


Ti     I  43 

J''ebro„cI,ial.I,n,,,.,,^ 

J'"^'-o  ..  .narkcl  intestinal  tubl  '  '"'•"•  ""''  ^'^^^-'"«- 

/  '"'vo  alrea.Iv  spoken   of   t) 
'"''^'■^'"l^n.s  plenH  SncI    .        T"''  '••"■"'^^"'   ^•"•'"   "f 

-'^— te  i„  onset,  cl.'oni.  a      ,:'"'"  ,  '""''^  — "ly 

■"'"""'  "^'^''^^y-atter/  i  ''"",'  ""l'  -"^-"«  '^  'urge 
"'^'';->"^  tl.e  32  cases  il  l  11^1'  "7''"'"^  ^'^  "^^ 
"-'  ^-••»  o.'  another  was  p.-esj     i    .         '    ""^  '•^""■'■«>-  ^^ 

^'-•«  "-ere  but  t.vo  with  mln.lent    1'  """-^"''^'-^"'""^  eases 

^^  ^"  --euh-us  pentoniti;  '■';;"  •\'^''^^'  "'^^''^  enough. 
-;eno-seIerosis,  who  had  .  ,  "  '"  "^"  "'^'  '"■•"'  ^-^'' 
-'«  "-'  a  -..-o-fihnnous  pe  H  :  "^f"'""  «"  ^'-  ^eft 
'-;--es  pncunococci  vvej  "nT"",  "  '■'"''^-  ^^  ^^»''' 
Our  clinical  reno.t^         i  '"  '''"  ^'^"'^''^e- 

^••"'•^^«,  d..  .,ot  intere  -t  us  sn  .•  ,,  ^•'"'"'«"^^'   ^nd   which,    of 

fcned  as  soon  as  possil.Je  fi-on  1-  '''"'''  ^^''^'•^  ''■-"«- 

'"r''.^'-'"«- cases;  inonfe    e    ;r'^f'^  '"   ''^  ^^^'''- or 
-'!--«.•  and  in  one  an  aun        f,  "'^^''^  ^'^''  "^  ^-'l^er- 

":  "'— '   and  one  I'  j^'''^'^?  ^^''"-^  -nee.  of 
««-os,s,.  four  cases  folJowod   ir  '"""  ^^'^''   --^^'io- 

;''f  --  oi--atcd  upon  1^^:^  ";;"'":•  '''"'^  ^-^  -- 

.'^'^''>-""o'-ver3.nnch'in,;..oved      ;  !  '?"f' ^  -•^'--  Pe- 


ij 


lii 


! 


^Ill 


i^  i 


44 


THE    SIIATTUCK    LICCTL'RE. 


Unfortunately  I  liave  not  full  particulars  of  tlie  bacterio- 
logical examinations  made  in  all  of  the  cases.  The  dotailj^ 
of  the  oarly  ones,  taken  l)y  aiy  late  assistant,  Dr.  Meredith 
Keese,  have  been  mislaid  since  his  untimely  deatii  ;  so  that, 
from  our  personal  experience  here,  we  can  draw  no  conclu- 
sions as  to  tiie  number  of  these  cases  in  which  the  lesion  reallv 
depended  upon  the  presence  of  tul)ercle  l)acilli.  I  would 
again  refer  to  the  somewhat  interesting  circumstance  that, 
with  the  exception  of  the  pyopneumothorax  cases,  not  a 
single  instance  of  tuberculous  purulent  pleurisy  was  met 
with  in  the  101  autopsies  in  which  pleurisy  of  one  form  or 
another  was  present. 

(c)     Chronic  adhesive  tuberculous  pleurini/. 

The  special  feature  of  chronic  tuberculous  pleurisy  is  the 
enormous  thickening  of  the  serous  layers.  In  all  the  ca.-es 
of  chronic  sero-fibrinous  exudate  the  visceral  and  parietal 
layers  were  greatly  thickened.  Post-mortem,  we  see  throe 
varieties  of  this  form. 

(1)  Primary  proliferative  tuberculous  pleurisy.  Aiiv 
one  of  the  three  great  serous  membranes  may  be  primarily 
affected  in  tuberculosis,  though  probably  in  the  majoritv  of 
all  these  instances  the  affection  of  the  lymph  sacs  is  sec- 
ondary to  that  of  the  glands  in  connection  with  them,  or  the 
organs  which  they  ensheatlie.  In  this  form  the  tubercles 
developing  in  the  pleural  and  pericardial  membranes  cause 
early  union  of  the  surfaces,  and  tlieio  is  never  at  any  time 
a  free  exudate.  With  the  progressive  growth  of  the  t.iber- 
cles  the  layers  bee. -me  greatly  thickened,  and  united  iiiiiv 
measure  from  1  to  2  or  more  cm.  in  diameter.  On  sectimi 
the  thickened  membranes  seem  to  be  made  up  of  diffu.^e  tuhcr- 
culous  tissue,  sometimes  caseous  liiyers,  and  much  filmml 
tissue.  In  the  early  stages  of  the  process  grey  and  grevish 
yellow  tul)ercle  nodules  are  seen.  With  the  exception  of 
involvement  of  the  bronchial  glands,  this  may  be  the  only 


tuberciil( 
Ijilateral. 
strictly  c 
exudate, 
lecently  c 
.'It  the  Uni 
day  of  an 
layers  on 
condition 
f.vphoid  fe 
(he  late  Dv 
adhesive  tu 
iiifrerjuent 
pockets  of 
back,  or  on 
at  the  .lohn 
able  case,  t( 
wliich  both 
were  enornu 
clieesy  mass( 
alone  there  v 
(-^)    Muc, 
and  ill  the  u|: 
("•anes,  there 
iliapltragmatic 
'Hit  sometime 
'^'''us  of  the  ; 
pleurisy,  there 
membranes  an 

'"   Connection 
Case  I.,  refe,.,, 

1)6  abrupt  as  in 

i'ecouie  greatlj 

'-ipt^ulated  sere 

f''e  left  pleura. 


H. 


TLBERCULOUS    VLKmuSY. 


uberculcus  process  i,.  ti.e  bo.Iv       I^ 
'^''"^'■'•al.      r  J.ave  seen   but  •  '''  ^"  ""''"^^'•"J  "'• 

«tnctly  confined  to  tl      ,      . '        l?'""""  '"  '"''^'^  ''  -- 
--'•■^'e.      One  ...  a   vo',      :,-"*''"'^'!"-^  -.,.o-fi,.,„,,, 

''■^y  "fan  attack  of     It„      '     '';''''^'''''' '''^'' ''"  ^'^ ''n-rd 

--iiHonjn.tde':;:r?;;::7'^!'''^^--'^- 

Wl.oid  fever,  vvln-ch  died   und!,"  I     "  '""""''  "'"'^  '^  ^'-^^^  "^ 
"'0  late  Dr.  K'o.s,  vvhe  e  1  '  ''"''  "^"  '">'  ^'>"«a^'ue, 

-"-i"ent  to  see  tin's'  oo        f^   ""^  "'^  '^^^"^^'""-     ^^  -  "ot 

^-  .  -  on  ti.o  diap,n.a,„.,i  :2^  ^^^f  ^^^f  ''^  ^'^'^^  "^ 
-  H-  Johns  Hopkin,  kospit.1  \  :  i;,/^'-  ^l'— showed 
al'le  case,  to  wl.ici,  I  si,,,!]  r..f....  ""'^^'  '^  '^'"a'k- 

"■''-'•  t^oti,  la,e,-s  of  the  pi  ;  ;  77  ""  ''  ''"  "'"-"^«'  '" 
were  enonnously  tln-ol<cned    -u  .'  '      .    ^""'^•^"''"•'y  ^''^  costal, 
cl-eesv  n^assos  .ere  pen'  '"     '";  '"T"''""'^^  ••^-'  '-•^- 
■^'0-  ti.e.-c  was  an  oL  I  j,  J  "  "'^':  '^^''-.-natio  su.-^e 
(^^)     ^^J"ci>  n,o,e  cc^r    ,       ''';"-fi^^'-'"«"«  exudate. 

-nes,  ti.e,e  is  separation  o     tI.e  ,  '  7  ''""'"'  '"^""- 

'''"l''"-a.^^>natic  surface  by  an  evnJ  .  '^'^^ovv  and  on   tI.e 

!-  -"-i.nes  contain;  ;:::::  '"'^"V"''-'^'^'-'""-' 
^''"«  of  the  32  cases  pr^serui    .  '""  ''"'^^  '"^'t^''"'-^'- 

!''-'-T,  there  were  I.>''.ie         "  J'-^-^o'-^-n  tuberculous 

'-"'.n.nes  and  ^ero-fibrinoi.s  Z^^^^'' nft"''''  '''''''' 
'"  connection  with    nJ,I        7  ''"^-     <^f  f'esc  six  were 

l«»n.c   ,,„,„|^  tl.iokcned.      r„  , ,  ,    """"''""«  Sn.Jually 
<»l''"l»le.l  aor„„,  eff,„i„„  „„,.    ,'  ''™"  ""■«  "'"s  an  e„. 


i  ill' 


^ '  1 


40 


THE    SIIATTUCK    LECTUUE. 


Imd  united,  and  ranged  in  thickness  from  1.5  to  2  cm.  In 
connection  \vitli  this  variety  tlierc  arc  two  points  of  vcrv 
great  interest.  In  tiie  first  ])lace  it  may  be  extremely  difti- 
cnlt  to  recognize  at  sight  that  the  process  is  tul)ercuh)tis. 
In  tiiis  very  case  of  John  A.,  who  liad  been  under  onr  care 
and  tapped  repeatedly  two  and  half  months  prior  to  hi,-; 
entrance  to  tlie  hospital  witli  an  acute  pnuemonia,  it  wna 
'only  the  closest  examination  of  the  dense,  thickened  pleural 
membranes  which  revealed  old  fibroid  tubercles.  A  super- 
ficial, maci'oscopical  examination  might  have  entirely  over- 
looked the  tuberculous  character  of  the  process,  as  the  lung 
on  the  left  side  presented  no  tubercles  or  caseous  areas. 
Of  course,  it  would  have  been  in  any  case  a  suggestive  fact 
that  at  the  apex  of  the  right  lung  there  was  an  area  oi' 
caseation  and  softening  the  size  of  a  walnut,  but  I  rcpoiU 
again,  as  it  is  a  point  of  importance,  that  without  the  most 
careful  scrutiny  the  nature  of  the  extensive,  chronic  plourisy 
on  the  left  side  might  have  been  overlooked.  The  sccdiid 
point  of  interest  is  the  fact,  well  shown  in  the  case  just 
mentioned,  and  also  in  the  case  of  John  P.,  that  a  chronic 
tuberculous  [)leurisy  may  exist  for  a  long  time,  and  lead  to 
great  thickening  without  any  extension  of  the  fibroid  process 
into  the  lung  itself. 

(3)  y\nd  lastly,  in  some  instances  the  fibroid  processes 
in  the  pleura  u)ay  invade  the  lung  tissue,  and  lead  to  exten- 
sive sclerosis.  In  only  one  instance  out  of  the  32  instances 
of  tuberculous  pleurisy  was  there  any  evidence  of  direct  in- 
volvement of  the  lung. 

Case  XIII. — Chronic  tuberculous  jjl^urisy ;  interstitial 
pneumonia, 

^Ym.  S.,  aged  (JO,  admitted  November  1st,  1890.  The 
patient  is  a  large,  stnmgly  bui't  man  ;  states  that  his  faniilv 
history  is  good  ;  denies  syphilis  ;  has  used  alcohol  to  excess; 
had  typoid  fever  five  years  ago  ;  rheumatism  six  years  ago. 


lie  came 
which  syi 
year.     IJ 
Has  iiad 
that  he  li 

Thoijrrl 

is  auiemic 
of'  good  d 
sion  on  tli 
axilhe ;     a 
breath   soi 
prolonged 
friction  soi 
lireathin'i- 
.Many  tube 
was  regard 
pliysema. 
and  on  the 
with  small, 
The  temperi 
as  low  as  1)( 


TUBKHCULOUS    I'LEURISY.  47 

wtr::;;;,:;:t';;::;«  ■■',  'i"---  »•■  '-h.  „„.,  „„„„ 
i,.l:t"''rru;o '"""--"^'^ =-' 

n«.o..  M,„„l  i„  ,|,c  l„„.o,-  l,.ft  „;,i,|,        ,  ,  ,''■''■  "  " 

7  '■"""■•''-I '"  »-  of  .„,„„„,,„„,, '^^"^;   ^'-  «» 

'«•'"    V    fib.™,    ten,         I     r     '     '  ' ■■  ""'""""- 

i»t™,.8,   dense  IbukI,    „f  fil„.„       .  """'"    ""    ""■ 

.I.C nose  ,„„k        ,t     „  ■",'°    " '"■«    •'"■""»-!' 

*«lv  fro,,,  ,1,    ,  ta.  ,  ,       ;','"?'  ""•'  ""'«  •"""'»  «'-''! 


■=''t  lung.      The  cuiKlition  i. 


'''"'^^'I'-ut  at  the  apex  of  the  right  lu,u 


48 


THE    SFIATTUCK   LECTUUE. 


tliiit  of  ail  iiitci'stitiiil  pncumoniu,  with  diluted  bronclii,  iiiid 
ill!  extensive  tuberculous  pleurisy  on  ;lic  right  side.  There 
is  ii  sinidl  tuberculous  ulcer  in  the  larynx. 

.'5.      (r'eiiey<(l  neroit-'^  inembrnne  tuberculosis. 

There  is  a  yruup  of  cases  of  tuberculosis  in  which  the 
serous  inendjranes  arc  ciiietly  involved,  either  simultaneously 
or  more  commonly  one  after  another,  forming  a  clinical  type 
fairly  distinctive  and  readily  recognized.  Tliere  have  i)een 
several  interesting  studies  of  this  condition,  notably  the 
Paris  Theses  of  ^Nloran  and  Boidland  in  1«84  and  18ti,j, 
and  the  careful  study  of  Vierordt.*  The  plcin-operitoneiil 
membranes  may  be  alone  involved,  or  the  jjleuro-peritoncal 
and  pericardial  surfaces.  Tliere  are,  as  noted  by  BouUaiul, 
three  groups  of  cases.  First,  an  acute  tuberculosis,  with 
rajiid  evolution  of  the  disease  in  pleuriu  and  peritoneum, 
generally  consecutive  to  local  disease  of  the  tubes  in  women, 
or  of  the  mediastinal  or  bronchial  lymph  gliinds. 

Second  ;  cases  in  wliicii  the  disease  is  more  chronic  in  its 
nature,  witii  exudation  in  both  peritoneum  and  pleunc,  the 
formation  of  cheesy  masses,  and  the  occurrence  of  ulcerative 
and  suppurative  processes.  In  this  group  the  pleural 
iiivolvement  is  much  more  commonly  secondary  to  the 
peritoneal,  or  both  may  be  a  sequence  of"  pulmonary  tuber- 
culosis. 

And,  third,  there  are  instances  in  which  the  pleuro-pcri- 
toneal  affection  is  still  more  chronic,  the  tubercles  hard  and 
fibroid,  both  tlie  membranes  showing  much  thickeiiiiiif 
often  with  very  little  exudation.  My  experience  witii  this 
form  of  general  involvement  is  not  great,  and  of  the  ?)\ 
instances  of  peritoneal  tuberculosis  which  have  been  under 
our  observation  at  the  Johns  Hopkins  Hospital,  in  only  one 
was  there  involvement  of  tiie  pleura. 

I  have  not  met  with  an  instance  in  which  the  three  serous 
•  Zfitschiift  far  Klinscho  Mcdeein,  Bk.  XI. 


i^  i\ 


TUBKl^CLLOU.S    I'LKUHISV.  43 

-Xri::;::;L'r ''"■■; '''7'^' -^^ ■-" 

...«y  1.0  «,„.„,,!^, ':,,::;;;,  x:  ':"r  't'™^ -" 

i.'.-eat  nnpruvement,   ,u„l  tl.ero  nmv   be      t  lo        '       ! 
Til,.  *..ii      •  .  .^      *'   iittle  or  no   fcvpr 

I1.C  following  ca«e  ..  ut  present  under  observation  : 

J!.  A   B.   c„l„™l,  „„«,  3„,  ,,,,,„^,     ,_,,^^ 
If  J,  c  ,„,,l,,„„„,,  „,■  „,„„;,  „,,   ^,^_^  ^^1  J        , 

--.W    ■„„,,.„,,,„,,  ,,„j  „,,„  ^,,,^  J -^^^ 

.'■.■-.,,i.*e„.  ii»»  n,,;w;:i  zi"'',:,:':''''^' 
«-  i„„o., .  „e .,.  e„„«„;d  ,„  :t;,  „  ,:::,:,,r 

""J  was  not  able  to  lie  down       Jle  1,...I  .         "'^.'""«"f''8- 


I 


50 


Tin:    SHATTUCK    LIXTUIJK. 


exertit)ii,  nnd  of  the  swollen  sibdomen.     He  liiis  n  little  coiij,r|, 
ftnd  slight,  scanty  cxpcctonition.       Patient   iy   a    niedium- 
sized,    moderately    well     hiiilt     man  ;     face    not    epeciallv 
emaciated.      Tiie    temperature    on    admis.xion  was    i)7.o-  ; 
rose  in  the  eveninjr  to  lUo'^,      lie  lies  quietly  in   bed,  head 
not  elevated,  no  respiratory  distress.      The  conjunctiva'  are 
a  little  yellow,  pupils  are  diluted.      Mucous  membranes  are 
somewhat  pale.     Pulse  is  regular,  !)0  to  the  minute,  the 
vessel-wall  a  little  sclen.sed.      The  brachials  pulsate  vi.^ihly. 
The  chest  is  well  formed  ;  costal  angle  good  ;  the  lower  part 
of  the  thora.x  is  expanded.     On  deep  inspiration  the  left  mh 
moves  more  than  the  right.      Percussion  gives  a  dull  note 
on  the  right  side,  beginning  at  the  sixth  rib  in  the  rccumlient 
posture,  and  in  the  erect  posture  at  the  fourth  rib,   the  diii- 
ness  being  distinctly  movable.      Ikhind,  when  sitting   up. 
the    line    of    dulncss   is   above    the  angle  of   the   scapula. 
Percussion  is  clear  throughout  the  left  side.     Tactile  fremitus 
is  dinnnished  over  the  dull  area  on  the  right  side,  and  the 
breath  sounds  are  feeble.     There  is    no    friction    mnrniur 
heard.      Ai)ex  beat  of  the  heart  is  not  very  distinct ;  pul- 
sation in  the  fifth  space,  just  inside  the  nipple  line.     The 
sounds  are  everywhere  clear.      A  needle  was   inserted   into 
the  pleura  and   a   serous,  greenish  yellow  fluid   was   with- 
drawn, containing  a  little  blood,  which  did  not  coagulate  on 
standing.     Cover  slip  preparations  of  the  serum  showed  no 
organisms,  and  cultures  on  agar  remained  sterile. 

The  abdomen  is  distended  and  large,  but  symmetrical  in 
the  flanks  and  a  little  prominent  in  the  umbilical  and  epigas- 
tric regions.  On  palpation  it  is  everywhere  soft,  painless, 
not  resistant,  except  in  the  upper  zone,  a  little  above  the  level 
of  the  navel.  In  the  whole  of  this  region  up  to  the  xi|.h(ii(l 
cartilage  and  the  costal  margin,  there  is  an  ill-defined, 
dougiiy  resistance,  which  terminates  below  in  a  tolerably 
well-defined  border.  On  three  separate  occasions  a  very 
definite  friction    murmur  was  felt.     The  ed"-e  of  the  liver 


TUHKHCULOUS    I-LKUlJlSr.  5, 

^'»;v:;:';*;;''t;;:v"'''''-'''' - » ■-•-■^ 

«i •!»  rji::,,:'"'':;;rn',;''°,*^'»'''-- >  i..v,,„: 

tin.    ni>.„l,.    r. ""     *"     ^''•'     costal 


iiiiir^nn     i,,     t|„ 


nip, 


Die 


JlllC. 


Tl.e 


'■'■'    '"'c    Jio    gl.'iiHiular 


e"'urgenK...u. ;     ,,0    c.deii.a    of    the    feet        T.  • 

='  i-^y  >-I  bluo,I  coi.pu.ole.       'J    ,  '  '""^•-yt'-vs,    and 

'^'-ve  100^.      He  Is        ^^  ,        '  '"'  ^^''^'^-'nituie  did  „ot  .^o 

^:^«^'"^"-v,lie,.,::c;1s;;::t^r'''"''^^^ 

tive,  *-*'  "'"*  "i»ays  been  nega- 

un";i',c";r.;;  i/tvtt"  '""="™'"*  -- '«. 

wa.  deeply   injected,  and   the  viscenl     "iv         '  J';'''^""^'"'" 

o.nei.tn,n  wa«   rolled  up     .nd   ^h  ^^^^^'de..      The 

■•'^-'t  tl.e  «to,.,aeh  and  eo'lon  "'  '""'  °'"'"'  ''"■'-•'^''^"'■"^' 

4  "'"■     "«  J'"™  Ws  illness  f,o,„ 


m 


52 


TIIK    SIIATTLfK    I.KCTHUR, 


tliis  timo.  IIo  Clin  </wc  no  details  an  to  his  faniilv  liistory. 
IIo  liiitl  fsypliilis  in  llie  spring;  of  IN.S!).  Tlu;  jiiiticnt  was  a 
nicdiiini-sizcd,  fairly  well  nonrisiicd  younff  man,  and  at  tin; 
firct  t'xainination  there  wero  fiirnH  of  disease  at  ixitli  apices, 
most  marked  at  tlu;  rijj;lit.  Tiierc  was  liin;li  fever,  and  very 
rapid  extension  ot  the  pulmonary  disease,  a  lari^e  excava- 
tion developiiif^  within  a  few  weeks  at  the  top  of  the  ri^fjit 
liMiif.  There  \ver(!  friction  eonnds  heard  in  tin;  axillaiv 
regions,  and  pivrtienlarly  marked  on  the  left  side.  'fin' 
aliilomcM  was  full  and  dist(!n(led,  sometimes  painfid,  and  lu' 
had  diarrhu'a.  Tlie  patient  did  not  improve  in  any  way, 
hnt  the  fever  persisted,  and  lie  became  <>reatly  emaciated, 
progresssively  weaker,  and  died  January  i?.")th. 

Autopsy.  —  Anterior  mediastinal  glands  caseous.  \]nt\\ 
lungs  were  hound  down  l)y  firm  adhesions.  'I'he  pleui:il 
membranes  thickened  ;  the  costal  layer,  easily  stripped  olf, 
was  covered  with  fibrinous  exudate,  beneath  which  were 
numerous  tubercles  and  caseous  masses.  On  the  [)ulmon;iry 
pleura  there  were  numerous  tid)ercles  and  flat  caseous  areas. 
Both  lungs  showed  large  cavities  at  the  apices,  numerous 
caseous  areas,  and  miliary  tubercles  disseminated  and  in 
groups. 

There  was  only  a  small  amount  of  clear  fluid  in  the 
peritoneum  ;  the  intestines  were  agglutinated,  and  on  the 
peritoneal  surface  many  groups  of  tubercles  and  flat  case- 
ous masses.  The  mesenteric  glands  were  greatly  enlarj^td 
and  caseous.  There  were  numerous  tuberculous  ulcers 
throughout  the  entire  intestine,  beginning  just  beyond  the 
pylorus  and  extending  to  the  rectum.  There  was  tuber- 
culous ulceration  of  the  bladder. 

We  have  many  opportunites  of  seeing  slight  extensioa  of 
the  disease  through  the  diaphragm,  cither  downward  from 
the  pleura,  or  more  often  from  the  peritoneum  into  one 
or  other  [)leura.  In  the  following  case  there  was  extension 
roin  the  right  pleura  to  the  under  surface  of  the  diaphnii^m, 
and  to  the  peritoneum  covering  the  liver. 


thy 
O'use   A'  I  'A       />  / 

^'-va.,>.le,  e.n.<.ia,c,l  •  ^  U  '-;  P-.-sM  ever  mmco. 

...(.■nai.g  cavity.      si,e  „.■,«   ;,     i  ^       '  "-"■*  "''  '•'""- 

''^'-  '-f  -ro„«  Huid  n    :  J    t    •;     r" '' '^ '-'^• 

OH\s.  '"  ''"''^  ^ej.ten.ber  12th  of  JKunu.p- 

I''""''''  l'--'"-i  nunu.n.us  iwr''"';    '•''''   """""•'   '*'   ^J- 
^'--     Tl.o  lu„,.  a.Kl  V  ,         '  °'''"""'"^  ^-''-'.^-  '..l>er- 

--dwit,.a,n.nCjr.^;:;:'^''f'^"^ 

'^'f'-nghout  the  left  h.„.    th^r'""''     ""   '"''''''  ^'^^'^^'^^y ' 

""^•"■•'-"■•'1  dilatati„n  of  a  bru         .  ,        '"  "'"'  '''  '■"I'f"''^"J 

The  under  «u,.f;.eeo!i:^'''*^''"''-"-T--te.T. 
"'H'orent  «tro,..I,.  ,,  the  \C^  T  ""  ''"  '''"^^''  ''^^^'  ^^as 

^-y  ^uberc,e«,  which  were  aL7L:::r!;^'l'  ''"'"^'-"''^ 
"i'P'''-8Nrface  of  the  liver    -in,!  fl  "''""'  ""   f''« 

•'"i,'es  about  the.n.  '  '"'''  "'"■'''  ""merous  lux^nua- 


r   1  ii 


54 


THE    I»II.VTTIJCK    LKCTtnR. 


Tlurc  \va8  tiilurcnlnii-*  ditieiisK  of  tlir  liiiiil)iir  vcrl«'l)i!i'. 
The  mi'i-cnti'tit!  ^ilatidtt  were  ciilar^'t'd,  lnit  not  cutteous. 
TluTc  were  tiibereiiloiis  ulceret  in  tlie  iN'iini, 

Attentitiii  lia.-*  ol'tcii  lieeii  ealled  to  tlie  t'leqiiciit  nssoeititiim 
of  tulierciilou!*  perioanlitis  with  tiil)eieiili)iin  pleurUy.  'I'liiis 
(.f  17  eases  vvliieli  1  recently  de?eril)e(l*  tliere  was  eonil)iiic(| 
(ii.-ease  of  tliece  iiieniliraiic.s  in  Cases  I\'.,  \'II.,  and  X\'. 
Jii  tlio  following,'  ease  the  periearihtis  in  all  prohahility 
followed  the  chroiiie  tuhereiiloiis  pleurisy. 

Cuf>e  X\'ll. — Clii'iinlc  luliei'culoiis  jth-inisij  ou  th<  Irfl 
side;  ncute  tubtrcaluns  pericarditis  and  pitnritix 
dextrn. 

.Toiin  1*.,  aged  thirty-eii;ht  years,  admitted  Aujiust  l)StIi, 
witii  suellinji-  of  the  legs  and  dyspmea.  The  fnnily  history 
is  ('Odd.  lie  has  heeii,  as  a  rule,  healtiiy,  though  in  his 
ehildiiond  and  youth  he  had  many  of  the  infeetions  diseases. 
lie  has  heen  a  moderate  driidier.  lie  denies  syphilis.  'I'lic 
present  illness  began  ahout  two  weeks  ago  with  pain  in  the 
left  shoulder  and  ahout  the  heart.  Feet  began  to  swell  ten 
days  a^o,  and  he  has  had  eough  and  shortness  of  breath  for 
about  the  same  length  of  time.  He  has  had  no  nausea; 
his  appetif  t  has  been  fairly  good.  Within  the  past  le^v 
days  he  has  become  much  worse. 

On  admission  the  patient  had  intense  orthopna'a  ;  pulse 
inO,  l)Ut  moderately  full.  He  hud  a  distres-ing  eoiigli, 
witii  elear  watery  expectoration.  There  was  great  (cdcma  of 
the  lower  extremities  and  of  the  scrotum.  The  finger-tips 
and  mucous  memi)ranes  were  bluish  in  colcr.  In  the  cx;un- 
inaticm  of  the  hcrrt  at  the  time  no  murmur  coidd  l)e  detected, 
but  the  second  ui;l.  wa^  accentuated  at  the  pulmonary 
cartilage. 

On  the  follow  i  .'jj  ■    n'-  v;^,'  the  patient  was  quiet ;  respirii- 

•  American  *^:ua.ui      tl.e  Medical  ScN  aces,  Jaiiuuiy,  1893. 


lions  i 
in  rhyi 
inislu'd 

Th(M 

pron.fn 
sides  '^( 
ril)  mill 
(iuineas 
"uineroi 

I'assjiifr 

sounds 

I'itch  of 

at  the  ri« 

On  fill 

'ine  nilej 

base  the 

Heart : 

slight  gen 

'ive  (hihi( 

tlie  riglit 

jiist  at  the 

at  this  poll 

tivc  dulnes 

tlio  nipple. 

intensify  ai 

Tlier    the  I 

''O  tOlld.         I 

ljeco,iie  assi 
(liastcilic  in 
pericardial  i 
base.  The 
'liiin  dtu'ing 
'|>ii<Ior  than 
''qii.il  in  vol 
sfornal  notel 


rvuf.Hcvt.ovH  n.Kuiusv. 


5'i 

'"  '''vH.n.  „„.|  force    tl.n.  I  i-  "'  "'''.^"'l''-  l...fl, 

•'"'"-^  -v,„.  |,,re  to    .   '"       r     "■'"■"'"••^  ''■'•«-  "-"1  H.C 

;:-••'-  ^i'>ii..ne  j;; ':.::;:  :;;:r7'''''-  -'''-^  ^'^ 

f>"  'M,sn.|,atio„  ,1.0,,  'o"  "  "'"""''"'^  <Ii".i"Hl.o.I. 

^'i.'"' .one..,  ,.e:i,;:::::;;;v;:r;'- '''^^^ 

"■^«  <'"'"o.«  oxfon.ls  outw.rd  to  .    '•'•'  "^  '"■'"•     '''^''•'- 
""--'.V  nt  ,1.0 /if,,,   snaoo  ■     i/      -''T    "''''   ^'"  ^"•^"'^•■«' 

r-"'-  ^-'•'." V;:  1'';;;:;;;;. ''''^  7"'"'' "'-^ 

leccuo  a.Hooi,,te.,  wi„,  „  ,,„„.-.  .  ;"\'''^'"'"".   „,o  so.,,,,,. 

'''''^'''''^''''''•-.'-.•.i,o...;  ::;7-^'^^ 
'-"-  ^'-'  '1.0  -o„;;o,.,i':„:r'" '""'"--  '^  "^  ^'-'^^^ 

"T'^''  -   vo,..,..o,  a..,,   „.e:n^-         '— 'ial,...,.o.a..e 
^'-•■''"<>toh;tl.e..ei.„ot.C,^ 

ii.lClloa!    (llirtriiiir  'pi 


J: 


'     f 


145 


•'''  TIIK    SIIATTUCK    LKCTUUE. 

illation  of  tlie  alHloiiiinal   organ,-*  is  negative.      The  mine  is 
yellow-col„iT(l,    acid,  i<j>.  gr.  1024,  distinct  trace  of  ail)n- 
niln  ;    several   iiyaiine  easts  were  found.      Tiuoiigiiont   tiie 
20tli  and  21st  the  i)atient  remained  in  nuieii   tiie  same  con- 
dition.     On  tiie  22(1  tlicre  was  a  slight  rise  in   tenipcrature 
to  lUO.o";   the  i)iil8e  varied  greatly  in  rate  and  character; 
at    noon    was   slow,  regular,  and   full,   from    70   to   i)0   per 
minute,  and   again  was  as  ra])id   as   140.      The  jiatient,  in 
many  respects,  was   better.      The  codema  of  the   legs  had 
disa|)peared.       'I'lic  urine  had   increased   in   rjuatititv.      On 
the  IDtli  only  l.S(»  c.c,  and  on  the  20th  ;].")0  c.c.  had  heeii 
l)a<scd.      On   the  21st  and   22d  the  amounts  were  700  and 
1100  c.c. 

2;)d.  The  temperature  has  been  between  97"  and  IKS'J  ; 
at  the  morning  visit  the  i)ulse  was  148,  regular  in  force  and 
rhythm  ;  the  respirations  ;]2.  The  patient  was  lying  quietly 
on  left  side.  The  physical  signs  practically  those  noted 
above,  with  the  exception  that  there  is  an  extension  of  the 
(tdema  at  the  base  of  the  lung.  The  patient  died  suddenlv 
at  4.30  1'.  .At.  to-day.  » 

Autoj.sy  (by  Dr.  Flexner) . —Large,  muscular  man; 
moderate  oedema  of  the  legs  and  of  the  subcutaneous  tissue 
of  the  trimk.  Fat  well  retained,  both  beneath  the  skin  and 
in  omentum  and  mesentery. 

Pericardium  is  adherent  to  the  left  pleiu-a  ;  the  sac  thick- 
ened and  contains  a  considerable  amount  of  clear  serum. 
Both  layers  are  covered  with  a  thick  fibrous  deposit,  look- 
ing like  a  hairy  coat.  The  thickness  of  the  pericardiiun 
over  the  heart  is  o  mm.  When  incised  the  thickened  laver 
18  grayish  in  color,  with  many  opaque  or  yellowish  points 
scattered  here  and  there,  often  con^-nuous,  and  having  the 
well-recognized  characteri-itics  of  tubercles  of  this  mem- 
brane. The  heart  was  gieatly  eidarged.  The  valves  were 
normal.  The  thickness  of  the  left  ventricle  was  17  mm.; 
length  of  ventricle,  8.5  cm.  ;   mitral  orifice,  10. a  cm.  in  eir- 


cuinfen 

ori/lce  ] 

''V|»pendi 

"hite  ni 

like  mu 

iHimcroi 

the  rigli 

cardiuin 

miliary  t 

The  J<: 

layers  ad 

t'lere  is  c, 

'i|>  u-itli  I 

The  diapl 

section  it 

t?inous,  g) 

masses.     ' 

touch,  and 

connective 

There  are 

tered  fibroi 

Therigh 

extent  free 

numerous  i 

glomerate, 

costal  pleiii'; 

■'ire,  here  ai] 

li)l>e  present; 

The  splcei 

of  !i(tfe  in  t 

present  tiibei 


!  !l 


TUBEacULOUs   VLKVUISY.  ,,7 

cumferenoo.    Ti.ickne.s  of  ri^l.t  venf.-i  I    r 

•"■"-«  '-^  -„.  i„  drc.„,„fe,,„:        T        '  ;  """•     '^'•'■'•"^i"-'J 

'^I'l-x'-   -•oal.no.t  oo„'     "k     """  ^^"'^-'^  "- auno,,!,.,. 

""'''I'T  n.bcrdos.  "   """"'  '•»!'•'<!<  wl.iii.h 

"»-:*— Nee";;    ^^  ?''''■' r ■  — 

■'-'<',  .ii..,.i..»«„„,k.  ,,,:.„:;■;:;;;,"■' -!■;  "-ke  -„„„„!. 

si""-,  g.avW,  ,fc3„e        "    r         ■■'„''"""'•  "'"■'»'  -"■"■'»- 

""""■ » -c,i„„  c,:!:,;;,  ■  •';;::"7"-'. '-' .-  .i.e 

Jlicro  r.n  a  few  sinaJI  r„:  ..,■     ?  ."■"""' ^  ""  «»lnliaili„„ . 

■s^=:rs£S-* - 

"tent  free  f.on,  adi.e.ions    |„.;  i  '  T"'""  ''^^''^  ''^^  'f« 

.^'-'orate,  whicl.  can  {,e  J-Tl    'T'""'  """^^'^^  '"'•'  <-'-"- 

nrc,  here  an.l  ti.e.v,  f,,.).   fi|,,i„       T      ..  ''  "'"^^  *'"-■'« 

lol-e  present.,  a  tVvv  fl,,.;  „f  n        '  '  '^I'^'^   '''*^  "PPer 

^'^'-spleenconi:;;!'"'"'"'''-'''--^' '"'-■-'-■ 
'•^--'"H-eaCiilj^^rr^^"!-'-      Xo„,n, 
P'c.H'nt  ti.bordos.  '     ^''^  ^"^•-^stinus  (lid  „^t 

I"-    Genkual  Patiiologv. 

"-™:*"i;;^Lr™,r:f °""'"™'-" -... 

"'"'  "'""  "1"'"  '"'y  .l.eci,,l  i,ccu. 


'( 


I  I 


I    I 


"jl 


0  i 


•)8 


TIIK    SlIATTLTK    LECTURE. 


I'unty  111  tlie  lesions.  :\rilinry  tuberoles,  with  inflimimatory 
exudate,  serous  orIiaMnorrlia<ric  ;  acute,  rapidly  caseatin^'  and 
ulcerative  processes  with  necrosis  and  suppuration  ;  a  chronic 
fihro-fubercle,  nodular  and  diffuse,  are  here  met  with  as  in 
the  lungs  and  elsewhere,— and  the  chief  interest  relates  to 
the 

Avenues  of  Infection. 
(1)     Doubtless  a  great  majority  of  all  cases  of  tuber- 
culous pleurisy  arise  from  direct  infection  from   the  lun-, 
a  tuberculous  focus  invading  the  membrane,  as  mav  be  sc^n 
any  day   in   the  autopsy  room.       Rapid  developm'ent  of  a 
fibruious  exudate  at  the  spot  controls  the  extension,  block- 
ing the  lines   of   transmission    and    limiting    the    process. 
Though  directly  excited   by  contiguity,  the  pleurisy  is  not 
always  associated  with  an  eruption  of  miliarv  granules,  but 
may  be  simple.     There  would  appear  sometimes  to  be  an 
antagonism    between   the   pleural    and   pulmonary   disease, 
and  it  will  have  been  noted  in  several  of  the  i)08t-mort.enis 
of  the  cases  previously  given  that  very  extensive  affection 
of  tlie  pleura  occurs  with  very  slight  or  even  without  any 
disease  of  the  lung  on   the  side  involved.      The  possibility 
of  infection  of  the  pleura  by  contact  from  tuberculosis  ,if 
the  mediastinum,  tuberculous  abscess  of  this  part,  and  in- 
deed from  cold  abscess  of  the  thoracic  wall,  must  also  be 
considered. 

(2)  rnfcction  through  the  lymphatics.  It  was  one  of 
the  great  generalizations  of  Bichat  when  he  spoke  of  the 
serous  membranes  as  '' grands  reservoirs,"  a  truth  demon- 
strated by  the  intimate  connection  known  to  exist  lietuccii 
these  surfaces  and  the  suljacent  lymph  vessels.  The 
l)cautiful  investigations  of  Klein,  Arnold,  and  others  have 
tauglit  us  the  complicated  anatomy  of  the  lymph  apparatus 
of  the  lungs  and  pleura,  and  also  the  course  of  the  Ivmpli 
streams,  so  that  it  is  not  difficult  to  understand  how  the 


f'erous 

bacilli. 

in    hois| 

attachct: 

i'fsj)irat( 

fhe  tracJ: 

are  bru,- 

t'le  night 

of  the  jxi 

iitfMcked 

qiithcliiii; 

'lelp  in  t\u 

ill  (lie  lun 

oytes  oft), 

(lie  opeiu'n 

fi'oni  tha  c. 

"hich  sui'n 

'"a";'  of  til 

attacked,  ai 

of   the    f„ll 

stroniii.      T 

"'veoli  pass  i 

too,  at  the 

'""^'  «f  any 

>'iit  and  fixe 

lobules  are  i 

tides.      L'Iti, 

glands,  whici: 

I'iiss,  nioi'o  am 

attached  to  th 

'■■'f^'  <'t'pends  1 
li.'ippily   f;„.   ,], 

gi-outh.      It  is 

'"  'lie  mode   ( 

i'ortion  of  indi 


TUBKKCULOUS 


serous  moiiib: 


W'KUitisr. 


'bacilli,,,,.,...., '1'?.'^:'^"^<^<J-   M' 


111    Ik 


r,    '"  ""'  •'"">''  '>"f  «I-eII, 


O  ;i 


'"  >"'ifile  tuber 


qntnl 


nrd 


•■'"■•'C'lic.I   fo    tlie   ,1 


'   ^•'■'•fainly  i„|,,,|e   f] 


«^'-^^  '■»  eiti,>8  and  work 


ust 


'•;«l>'"n.tor.v.  system  i.  u'ell 


i>i<i'ticles,    tlie   / 


;e"i    verv  rroquontl 


^f"   "f  wliicli    in    ti 


,1     .  "     ^ -•-...  ,o  we     known        \  .  '"^ 

••;'■''  '^'--^''^I  '.y  the  cilia    o    I     ,    "'  '*^'  ^'"  '«'-«°3-te.,  and 

^''^"'>''t.••P|.c^.rint!KM^r    .'■''"''    "'^   «"'-P'"S-«   of 
"^'  ^'-I-'-'iclo.  read,  tie    L^^^^^  Many 

■•'^f''^'^«'  h  tl,c  ;,,r<.e  d,  '  ''""^  "■"  '"•'•«  "'«o  m   Part 

'-'i;'''/'>oo.,neral8eaven.-ervo  ;,;"''  "'  ""  •'-'^^'  ^'> 
"';''^""^-  ^^-'taeon^n':  t  "''"""  '"^--'"^'v 
y^es  of  the  hronehial  tree  .n  T        "^^"I'^  ^'^  I>'"^C^o- 

;'-^i---.-n  the  h.tj^^^^':;   ^7''' -'' P- through 

"'•^'V;'  "'^  ''-  J,n,ph  nodes  t  '  ''"'"■" '"''■^■^  ""■-^^h 
•■'f  "■'^■^'''  ■•••"'  "->y  of  the  :.;;!"  ""^  "'  "■'■'-''  ^'-^y  are 
"^    ^'-    ^oliindar  cord,    o  ^  '"T"'.  «-"  '""  ^''o  cells 

;'^-^'''' 17  >"^o  the  wide  s.^!ij;;'' '';-""- 

"'•'  --^^  "'0  poripherv  of  the  ,'      ""''''  '^^'"■•"-^-      Ifere. 

'''"^'  ''^ --  adult,  ;nanv     f        '%-''^ '''•■••^'  '^^ 

'^Ij-'c^  are  aocuratelv  n.anne,        /  P     ''  ^^"  "'"'  "^'^^  the 
"^'--      L^'tnnatelv,;e      ^"'^ '''''"  ''^■'>'-'M'ar. 

'•"^'^^"'o.vandmoro.lee';  '    "  '"  "^  "«'  ''•'^  ^'-o  years 

''  .f''-'^'^  vor,  n,ueh   u     „   t     "  "'7  ••""^--  -"J  their 

"•  "'^  •"-'«   of  in(ec,io^  2      ;"•"■'  "■'"•  "^-"- 


!/ 


I  ! 


fiO 


THE    SIIATTUCK   LECTUJfE. 


nodes    of  tlio   respiratory  system    niuy   he   called,   tubercle 
iKicilli   efFcet  a  lodgement.       Indeed    there   have   heen    im- 
portant oliservations  uithin  the  past  few  yeai-s  to  siiow  that 
tiic  Imcilli  may  be  pre.-^ent  (witliont  having  caused  any  mis- 
chief) in  apparently  healthy  lymph  glands.      There  is'direct 
communication  i)etween  the  sub-pleural  lymphatics  and  the 
sac  of  the  pleura,  so  that  it   is   possible  to  conceive  of  a 
direct  entrance  of  the  bacilli  in  that  way.      More  commonly. 
Iiowever,  the  disease  spreads  from   a  sul)-plcural  nodule  or 
ii  lymph  node  in  whicli  tiie  bacilli  have  grown.     The  wide 
and  free  anastiimoses  which  have  been  demonstrated  to  exi.-t 
in    the   lymph   vessels  of    the  pulmonary  pleura   favor  the 
rapid    diffusion    of    the     virus    under    suitable    conditions. 
Possibly,  too,  in  some  instances,  direct  infection   may  take 
jdace     from    the    bronchial     and    tracheid    lymph    glands. 
Under  all  these  circumstances  it  is  tlie  visceral  layer  of  tiie 
pleura  which  is  involved.       The  lymphatics  of  the  parietal 
pleura  have  wide  and  extensive  con)munications,  discharninn- 
as  they  do  partly  into  the  lymph  glands  along  the  vertebras 
and  partly  in  the  anterior  mediastinal  group,  along  the  in- 
ternal mammary  artery.      Infection  may  come  from  tiie  Iviii- 
phatic  glands  in  the  neck,  particularly  the  supra-clavieiilar, 
which  conununicate  freely  with  those  of  the  axilla  and  of  the 
sub-maxilla.     Infection  of  the  pleura  in  tuberculosis  of  the 
glands  in  these  two  groups  has  been  frequently  noted,  and 
has  been  made  the  subject  of  a  special  essay  by  Hernandez. 
In  rare  instances   the  disease  may  extend   t(    the  pleura 
from  tuberculous  caries  of  the  bones  in  the  neigliborliood. 
An  interesting   instance  of   this  was  reported  to  the  Jolins 
Iloi)kins   Hospital    Medical    Soci(!ty    by    Dr.    Flexner    last 
winter.      A  colored  man,  aged   24,  had  a  sinus  in  the  neck 
which  led  to  an  erosion,  involving  the  outer  third  of  the 
right  clavicle.     The  supra-clavicular  glands  in  the  neigiihor- 
hood  were   involved,   particidarly   the   group    between   the 
clavicle  and  the  upper  border  of  the  pleura,   which  were 


expectoration 


'iUHKKCULOUS   PLKUHISV.  (jj 

tnlaroed  and  caseous.     The  ri.rl.f  o,.,.  i     , 

i.-i tic.  ...■ XZ:!::'  "'•""'"  """-•  "'"■  "•« 

IV.      I)lA(i.NOSIS. 

-->"'" » ..io..ri,v,  c ;:!„:"'  :;TV  """? 

a  .lia."no.i,.     X  i, ,  ,-     '    ,  "  ''""  "I""'  "''i'^''  '"  '»- 

o™*;.o  ,„„,■"  ';    °  """■^'••."'-  ""■•  '"'"»"-  "f  .1,0 

-.-...,,,,,  ,,,,„^ J--, ^'3. «><^ 
.1,  ii,v,„,  ,1,  :„ : ,  ""■ :'"''' '"'  "'■  i«'«  '• .1 .0 

'"i«'|'-"i"us  „ic,„.i.v  „f        :  •  '"  "■'«•''  """- 

'-. '•:::i:o.:;: ':;:,:■■  :r:';''- 7' ■'-'"''■• 

»anl».     I  have  .,lrp.„l„  ,.  li    ,  "  '™"'  """I'"'! 

.|.ccidlvi,,      ,,     ;;  '•X'""'^  "'f  "•■"  •"  ""  P.."..s  ,„  1,0 

"■-»-■■ .';:;::;  :'ni;r!::;::;,«;::;;'"-v»-«»-'. 

tii^uou.s    to    the    nlenr.     tl,.    "       ''/"   0  "'P'' ^^lan.le  con- 

- •--v::r:;r:,r::s^^^^^ 


fljiifj  i!     I 


!l 


(;2 


TIIK    SIIATTUCK    LKCTUUR. 


a  very  siiuill  fixMis  of  .^ufteninjj  tubercle  in  comiminiciitinii 
with  the  l)riiii('lui!S.      On  more  tlian  one  occasiion  it  iiaa  hfi])- 
pened  that   tlieir  iliscovery  after  repeated  exaniiiiatii)n   Ims 
cleared   up  tlie    i  'itnre  of   an    ohscure  pleurisy  ;    and   it  i,s 
worth   nolinjj   that   in    Case  I.   the  only   spot    of  fsoftenitiL; 
from   which   the    tuhercle    bacilli    coidd  have  come  in   anv 
numbers   did    not  exceed   the  size  of  a  hiizeliuit,   and   wns 
in   tile   \uu<<;  on   the  iside  opposite   to   that  of   the  elliisioii, 
The  physical  chara>'tcrs  of  the  exudate  offer  in   a  majoritv 
ot  instances  nothini;-  distinctive.       A   luemorrhagic  exuda- 
tion is  suiTgestive  but  by  no   means  distinctive,  in  as  mucli 
as   it  may  occur  in   cancer,  or  it   may  occur  with  ordinarv 
simple  pleurisy,  as  in  two   instances   in  our  list.      It  is  im- 
portant to  note  that  the  effusion   may  be  hosmorrhagic  in 
either  a  chronic  or  in  an  acute  form.     I  call  to  mind  one 
instance  in  which  the  presence  of  luvmorrhagic  exudate  led 
us  to  suspect  a  terminal  tuberculous  pleurisy,  but  there  were 
no  tubercles  on  the  membranes. 

The  bacteriological  examination  has  been  made  now  so 
frequently  in  acute  pleurisies  that  there  are  facts  enon<>li  at 
our  disposal  to  warrant  a  somewhat  definite  opinion,  ami 
the  general  conclusion  is  tliat,  except  in  very  rare  instances, 
the  serous  exudates  are  sterile,  and  tubercle  bacilli  have 
only  i)cen  detected  in  a  very  moderate  number,  in  only  l\2 
cases,  according  to  the  recent  article  of  Prince  Liiduj^' 
Ferdinand  of  liavaria.  The  inoculation  of  the  exudate 
into  the  peritoneum  of  rhe  guinea-pig,  which  has  been 
practised  in  many  cases,  also  gives  variable  results,  hut 
when  positive  is  of  great  value. 

The  inocidalion  with  tuberc(din  is,  as  mentioned,  micer- 
tain,  and  I  may  state  here  an  instance  in  which  it  led  u> 
into  error.  ,[ust  as  we  were  beginning  to  try  it  the  late 
Dr.  Christopher  Johnston  sent  into  the  wards  a  vmiii:: 
woman  aged  about  28  or  29  with  a  bunch  of  enlaiged 
lymph  glands  on   the  left  side  of  the  neck  and  the  axilla. 


She  was 

but  of  ofj 


nurmg  sei 


i* 


TUBICliCULOUS   PLKUIi.SV.  ,50 

»..J  axill.,.,.  rci,  ^""l'''>'i-.J.  ...  ,1,0  M,l,.el„vle„l„, 

.'.■i T  .I.--..X :,,!::;  "''"'■'™'''™""-'-'''« 

of  «  -.Im,.  i„  ,la.  Ic^   ,  '    ■■"■""""""  "'"""  'l.=  »i» 

:..  |..--.i»,  I  »„    .  "•.■.™l-,cc.  „.|,i,|,  „,.  ,,ll  ...oe, 

^  "111.1111011  to  the  cumlition  of  th,.  |„-,...  f 

depend  upon  infection  with  .tren.o.oeei  ,''"'' ^'^''^'^''-f- 
"y  the  staphylococci  Tl.,.  f  ,  '  ""V  '  '^  i"'^'"'"*^^'occi, 
-Hi  in  some  .c"  e..       ■  !    "t^     '"""  '"'^^'  ''  I^^-^ 

""'-  the  efFu«ion  i«  .teiile.      The  cm.!,  '       ''  '""*-'- 

;  " -^ "*'"•'   ""coiiinionJv  tuhcTciil,,,,.        t 

■•'l-emly  mentioned,  the  fluid  may  „ot  he't.  "     ^^' 

li'e  mo.t  .u»|„c.on.  usance,  are  tho.e  i„  .vhich 


i,    tn 


f 


^^y  I 


ill 


THE    SUATTLCK   I-KCTUUK. 


tlie  fluid  oontfiiiitly  recurs  in  Kpite  of  repeated  tiippintrs 
and  ill  wliicli,  witii  (liiiiiniitioii  apparently  in  tlie  anjoiint  nf 
exudate,  the  flatness  persists,  usually  with  traiisini.-^sioii  (.(' 
tiie  taetile  Creniitus,  and  sometimes,  as  time  proceeds. 
n)arl<ed   flatteninn;  of    the  afleeted    side.       The   ree()rd>^   ,„' 


;ises 


I.,  IX.,  X.,  and  XI.  show  a  sequenee  of  events  oidv 
too  eonnnoii.      Possibly  some  of  iliese  eases,  with  flatter 
at    the    l.ase    and    slight    retraetion,    heal,   and    no    further 
trouble  oeeurs.      Certainly  they  are  not  alwavs  tubereni 


iinL' 


Ull.- 


Wlli) 


1 1  ess 


sueh  a  process  may  follow  a  simple  sero-Hl)rin()Us  pleurisy 
or  an  empvivma.  Tiius  in  a  vounij  woman  ji'a'd  2',] 
was  admitted  to  my  wards  Xovendjer  17th,  18!)(),  with 
riyht  chest  Hattened  behind  and  at  the  sides,  with  did 
at  the  right  base  and  curvature  of  the  spine  (and  who  died 
of  aniemia  associated  with  syphilis  of  the  liver,  and  Ivni- 
phatic  nodides),  the  right  lung  was  firmly  adherent,  the 
l>Kiual  membranes  were  thickened,  particularly  at  the 
extreme  l)ase,  and  between   the  thickened  layers  there  was 


a   cavity   eontaiiung   about    70   ec.    of 


!in  opaque,   w 


thud.      The  cavity  presented  adherent  calcareous  tl 


liiii>h 


iu<es,  and 


there  \\as  no  caseation. 


uncommon    m 


Su 


ell   instances  are 


jy  no  means 


traction  anil  flattening  at  tl 


post-mortem  work,  and   unquestionably  eo 


11- 


le  l)ase  and 


slight 


the  shoulder  may  persist  for  an   indefinite  niunber  of 


drooping  of 


perlnqis  a  pro- 


without  leading  to  any  more  damage   than   perl 
giessive   bronchiectasis   in   the  lower  lobe.      Clinicallv,  t 
these  cases   are  not  very  infrequent,  and  thou'd 


years 


no. 


1   one  uKiV 


lia\ 


e  a  siisi.ieion  from  the  history,  yet  good  health  iiiav  be 


maintained  for  many  years  and  cvid 
wanting  of  any  tuberculous  process. 


ence  may  be  entirely 


V.    T 


I£KATMENT. 


Tl 


tl 


le  indications  are  two-fold  ;   first  to  limit  and  eoutivl 


le  exudate  and  to  promote  its  absorp 


tion, 


It 


would  till 


inc  far  away  from  the   immediate  subject  to  discuss  I 


licre  in 


TL'B|.:i!CU[,OUs    I'LKUinsv. 


-luoo  „,„  ,■„..,,      '■   .      "       '"■  ■'  --o.  "i, i,„„,  ,„ 

I ci» fk,.i,. „,„,,„,   J';.    7";."f"'f- »"'!  •■>  ko.,.  ,i,c 

r—"^^'" «-*"::::":;;:;'"■ 't'f'^'"'- 

"'"'"■I"'""  ""™'"  'Uoa„„c,  ,„.„  :„M*,I       I,  i    ■   '""""" 
l'>  raiiciiil.ei-ilm(  ivlicn   H,h,i  .  ""|"m,int 

'i'"-yK"".n«,I,     ,  ,  """*  '"  ""■  -''"' i' i- I".- 

Tl.e  di,„«i„,    „,,   r°   ,'™  "■"  '■■'"''';"°  '«""-*  .■;,,,MK, 

=        tirm,l.,„„g,l„.  Iy,„,,l,„„c,„f  ,l,i.c,„ia|,,|„,„,,,.. 

i:™;;S;':ife,;;»*2;;;;;;...;,,,,,„ ,, „ 


H 


(50 


TIIK    HIIATTUCK    LFXTUlilO 


111  tiio  ciisL's  of  I'luoiiit:  scro-flhrinous  efru.sion  witli  tliiok- 
t'liiiiir  of  tlio  iiieiiilniiiu'B  tlio  fluid  ic-iiccuiimlates  rnpidly,  iinil 
iifpiratiuii  may  liave  to  l)u  pcit'urmed  very  many  timo.-i.  In 
tlief<e  iiit<taiu;c'S  systematic  pulmonary  gymnastiufi  slnuild  Ijt; 
jiractitied.  Tiic  e.\|)an.-ise  elUnts  of  Corcing  water  fmni  one 
laiye  Woilt'tj  l)ottle  to  anotlier  is  a  good  mclliod.  Wiieii 
the  exudate  is  pundent  the  case  siiniild  lie  transferred  to  tlic 
surgeon  for  tiiomuyli  drainage. 

Tile  second  indication  is  to  improve  in  every  way  posjiililt; 
tlio  general  nutrition  of  tlie  patient,  so  as  to  favor  conditions 
promoting    tiie   iicaling   of    tiie   tul)er 


culoiis    process 


X, 


doubt 


,    as    111    pulmonary    and    peritoneal    inlection,    mai 


instances  ot  tuberculosis  of  the  [ileiira  recover  and  leave  no 
more  damage  than  that  associated  with  sliglit  thickeiiini''  of 
the  mciiibrane.  A  life  in  the  open  air,  regular  habits  and 
exercise,  a  nutrious  diet,  and  the  use  of  the  remedies  wiiich 
promote  in  every  way  digestion  and  the  assimilation  ot  food 
should   be  advised.       And  finally  we  may  lay  to   heart  the 


words  of  Sir  ^Vmlrew  Clark 


\V 


Hen  we   have  a 


patient 


with  l)asie  liljrinoiis  pleurisy,  let  us  hold  him  fast,  restrict 
his  freedom  and  treat  him  carefully  until  every  reiiinaiit  of 
it  is  irone." 


1  iliii'k- 
Jly,  11  nd 
e.s.  In 
iiiiild  l)L' 

■ one 

When 
1  to  tlic 

)()ssili|ii 
iditioMs 
I.      No 

iiiiuiy 
'iivi!  nil 
iiing  of 
nts  Mnd 

>  wliicli 

of    t'(M)(] 

ait  tliu 
piuit  lit 
rceliict 
Hint  of 


'!j 


k_  X  ».  X  I 


»/ 


FMIT  W. 

THE  DIATHETIC  DISEASES. 

TUBERCULOSIS. 

By  WILLIAM  OHLKli,  M.I)., 

BALTIMtlltK. 


I.  General  Etiology  and  Morbid  Anatomy. 


{<})  Incidknck  nKTfUKKci'i.osrs  i.\  I 


it  liiis  luiiir  i„>on  known  tliat,  in  the  (lu.'iint  I 


Nrwcv  AM)  ("im.Kirdui). — ,\ 


n^Ni;i;,'('  uf  Sir  Tli(ini!is  I 


'(•onHuniptivc  iiiid   tiil)iil    nx.ts   spioiit  early,"   the  appreciation   of  tl 
pfead   |ii'e\.ilence  (tf  tiihereiilosis  in  the  early  periods  of  iif 


hliitiiifli 

•  I'liWIic, 
ic    Willi'- 


observations.     Kxt 
niontlis  of  life,  tli 


('  IS  due  to  ivvciit 


veai-  and  in  fl 


reiiiely  rai'e  in  the  new-horn  and  iinconnnon  in  tiie  tiist  tl 
e  eases  increase  rapidly  throii^rhoiit  the  latter  half  of 


I IV 


le  second  vear. 


the  year 
tub 


IS!  It  I 


In  the  rn''-rl„'  of  the  llopital  Tenon  of  I 


erci 


If  IS  stated  that  more  than  lA   per  cent,  of  the  hahif    , 

ilosis.      Of  i',")7t>  autopsies  on   infants  made  at    Kiel,   Holt/,   fmiiiiriji 


ilic  \'m 
■•in-,  ;!i 

dlCli  nf 


cases  of  tuberculosis.      The  followin 
ages 


;r  tabl 


e  ;;ives  the  proportions  ai  A\\]v]w. 


Iiifimts  l)( 


!• 


rorii  (I  to    4  weeks 


(i  "  12 
I  "   -z 


10      " 
•')  montlis 


(Ml  per  1(10    '     ]■' 
(Ml    "      " 
0.(1    "      " 
S.ti    "      " 

i«.;{  "     '• 

2(i.8    "      " 


to    .!  vear* 


10  ■'  1.- 


.  ;t;!.(i 

.  •-".i.() 

.  :{|.s 

.  'M.w 

■  30. 1 


)cr  101) 


The  statistics  of  the  late   Prof 
under  three  yetirs.     Of  these  there  were 


essor  Parrot  embraced  '21'^  case 


•s  III  Liiilmvn 


From  1  day  to  .'{  iiioiitlis >>^ 

"        •'{  to     ()  niDDlhs 'jr. 

tl      .....  ........... 


ll 


)3 


givinn:_  a_  total  of!  11  umh-r  one  year  of  ar;e,  and  from  one  to  two  vcaix  lOS 
()t  .)00  autopsies  iii  children  at  the  Munich  Patholo^rjc,,]  Institute,  Miilj 


loiim 


1  tiihereiilosis  in  1.^0.     Of  .■,27  infants  dead  in  hospiFal  of  various  ,"| 


tubercles  were  present  in  :]14 


140 


set  of  combined  autopsies  on  2280  children  .rave  T",:]  tul 


7  non-tuberculous.     Tl 


le  ajres  ul  the 


tub 


iseasi's, 


)errillnll.s  llll'l 


erculous  cases  are  thus 


u:r'iii|ii'il 


Fnmi  liirtli  to  1  moiitli ]( 

Iji  to  2.^  yi'iii-s .    .    . 

h'viim    .S  t(j    ■)  viio-s     ....... 


11   "  1.- 


94 


25.5 
22ti 
124 


.\  ialoi{ous 

liiii  lie  observ 
y.  ;iii;  rate,  tb; 
I.  .Ih'  lifteelili 
:ii  till  ^liiiids.  - 
,i<i''*  111  the  out 
'if  iMildi'cn's  d 
TLe  tiiortali 

1 1-  n>c  after  pnl 
inlii'niilosiM  in  t 

I  till'  di'Vd  to  th 

I  III'  fificetitli,  ."!. 

I  •Mikiiiu'  manner 
ri'l.  Ill:  in  th 

:iii' tenth.  14;   f 

|A|  Thi.;    n.A 

.■:i|i.iMc  of  ex|)r( 

'iiMiiisiii  diseovt 

ill  li'ii^'tli,  ami   I 

hiviic  the  bacilli 

I  SIlL'lt'. 

Kiir  deiiionstr 

siii'fiictory :  The 

!«i'li  ii  small  sha 

lil'iwod  to  dry  ii 

i:uiii'.     .\   few  di 

]'"'  L'l'aiiis.  carbo: 

■111'  iilaced  upon  tl 

iiiij.     The  i.'lass 

.■nliitiiiii — naiiielv, 

nlgnmis — ar(>'p 

Iriiiiiiitc.     The  ^r],.| 

I'H'  drying  betW( 

|staiiK'(lrod,  while  t 

hi  sect  ions  the 

"f  the  -loiiiis  llopi 

I'lli'iliol  and  imbedi 

l'*liii  slimilil  b(>  re 

[etlipr.    .\fi,.i'  this 

IfliiT).  ami  ihei,  pla 

i-tlie  carliul-fiKdisi 

I  ifiiiporature  of  (;()° 

"i-i'i;'lit  lii.iirs  in  th 

[tajieratiiiv).     The 

''''■lllelisin.       .V   IT,,, 

'■•'""•'tory  (acid,  hvi 

finnTss  must    ln>  '(.. 

[funu'tcij.  III,,  tuber 

I  i' IS  lust  to  |V„|ov(. 

(""■"led  pink  tint. 

I'l'Wlt.  llipici.lls.sol 

11 ''"lor  from  the  ti.- 


'J'iiii:i{('i  t.osj^ 


A  laloifoiis  >(ati.sficH  ar,.  ,i„f    t 


»/i 


hilt  iiio  <>l).H('rv)itioii,s  of  N'ortI 


O    III 


.V  know  I, ..I;.,.,  iiviiilahio  i„  tl 


itiiti;   rate,  tlmt  tlic  i| 


"ipiit   till.  New  V,,rk   1 


til  ill' 


tith 


I  till  ;iliint|H,  nki 
t) 


'••ntii  vrar  tiilxTciiLmi 


i>«'asf  iiiiiMt  picvi.il  ,,iiit, 


"lllilllM^r    Asvlll 


•  IN  country, 
III  >Im»w. 


II.  ami  Imiii 


•"^  I'oiitriliut 


IX  alnii  vtTv  f 


'i''«'xt(.nsiv,.iv.     Kro'ii,  ,|„,  ,|,ini 


i'"''|in'iit,  aii(f  it 


iw'M  111  th(.  „Mt-pati<-t,t  .Icpartim.nt.M  of  | 


'■  n  Vi'iT  r(»ii.>i(|(.ii,M,.  pel 


'!■  IMildn-ll   M   (list 


ast'.s. 


l<>"<|>it!ll.S  1111(1 


"<  iiiaiiifcstiitioiis 

■•••'lltllL'<'  ut'illl 


•'i"'-tality.  Iii;,rl„,.,  i„  th,.  (i 


III  llic  special  iiiliii 


iiancs 


.ll>r,ltl.Tpill„.rtv.      Tliiis„n(),()(.o"| 
ihi'iviilosis  in  ill,.  fi,.^t  ^.,,,,,,  m 


Inl-i",:!,  ■:''''':'  '•'r!''^'''>-'''';:li''''f.'liiNI 


ivin-,  tlicT..  .lii.([-.  s.  ( 


tilt'  til 'I'd 


to    til 


lilt 


I.  1'.!':   t 


III  the  sccoimI,  III 


III'  Hlimilli,  ;{.:!.     Tli,.  Ki,.| 


I'oni   III,' 


111 


'iki 


iiml 
IliiC  tciitli, 


ii.u'  nianiici-:  of  III  niio  i 
lit 


,.      'fli  to  the  t,.|,t|,.  o.   j.,^^||^    j 
""""'lit  V  statistics!  I  |,.l|,.r)  also, si 


IIIMIlj, 

yiisiis.  |«7o)  ,,j- 

I'din 
H'  tcntli  to 


III  the  tliinl.  ;",.<»;    | 


'yiii;r,  tlicrc  died  i,,  i|„.  ( 


low  this  in 


.|'/t'|■-'■^«^«^•.^:.|«:H,.;u,':,,;;■■;r>r'■^^:^;"•' 


a 


14:  I 


'■'""  '!"■  ti-ntl.  to  the  firte,.,itli.   1 


'iftli,  ••54:  fVniu  till.  fiCtI 


ic  see- 
to 


{>•)  TlIK     H.ACII.M  s    Tt 


c'ljiaii 


Ic  of 


i)i:n<iM)sis.~It  i,. 


expressiii^r  ,,„  „,,i„j,j„  (|,„j  f,_^ 
-;""■"'  '''■^i--<)Vi'red  l.y  Koeli.     'l'),c.  l,a,.i|| 


H'  esseiitii 


1  k'ii''t 


lick  now  led^r,.,!    |,v  f|„ 

/""i^c  of  tiil)e|'cu|.,sis  isih 


ise    most 


"IKI    iisiiallv  a    littl 


twiic  I  lie   ha  CI 


Hi 


c  curved.       In   t| 


lis  IS  a  short,  fine  ,,„1  f,.om  1 


li 


I'll 


"'■'•  often  in   little  cliiiii| 


piitiim  and   in   tiilMTcnl 


w,  or  two  li,.  crosswise  at 


oils 


"I'  'iciiioiistratiii;;  the  l.acill 


an   aciii, 


MitJ.'fm'tory:  Tlio  thicker  and 
I'll  11  small  sliarp-poii,t,.,|   f 


'  ill  ■'^piita  the   followii 


illliiH 
lillllll', 


Inn 


oil   to  dry  i„   11,^.   ,,j,.   ,,„,,    j,_   _ 
■\   lew  drops  of  Zi,,|,rs   ,^„i 


'loiv  purulent  jiartsid'tl 
oiveps  and  spread  over  tl 


1^'  method  will  I,,,  found 
^I'l'tiim  ar..  picked  out 


leii 


passed    three  or  four  t 


lie  (•over-;rlass,  which 


:r;ilii.« 


■  |il;ici 


earholic-acid  crystal  ,") 


iitioii   of  fuc! 


lines    throii.di  tl 


upon  tl 


>  J-'rams,  alcohol  10 


cism— nanielv,   distilled 


is 
le 


water 


iHll. 


IC  cover-^rlass.  whid,  is  held 


•"liiliiiii — II 
!  I'i'l  I'l'aiiis — 


■  I-*  then  washed  in 
'ii'icly,  methylene  hliie   | 


ovcr  till 


:i'iiiiis,  fiichsin  1  ^ram— 
c  until  it  he^rius  t 


lam 


■are 


iiiiiiiiit..     The  <A 


lalii'V  ilrviiiir  1 


[•'need  upon  the  .rla.- 
:i^*'<  is  then  washed 


l'«'i'  cent,  sulphuric  acid 


to 


Ln-aiii> 


1) 
iriist's 


aiiufd  red,  while  tl 


'letween  filter 


■paper,  in  oij  ,„•  ),j, 


mill  allowed  to  remain  tl 
III  "liter,  and  mounted  citi 


111  scrtions  the  f 


IC  iiiiclei  of  the  cells  and 


<aiii 


'I'll 


lere  for  alioiit 
ler  ill  water  or. 


,h 


onowiiiii- 


'iiiy  other  liactei 


'nil 


111^  Hopkins  II 


I'll  and  imbedded 


OS 


pit 


""■tliod  is  pursued  at  the  I'atI 


tii'iercle  haeill 
ill  iii'e  stained  I 


lie  tissue, 


H'mi  slio 


iild  h 


ill  celloidin.      After  tl 


lolo^ri,.;,!  Lalioraf 
'"'"I'l  ''I'  liardened  in  al.sol 


1  are 

due. 
ory 
lite 


HlliT. 


A  ft, 


removed  either  with  oil  of  olov 


IC  sections  have  I.eeii  cut,  the  cel- 


this  thev 


lie  far 


iiii'l  then  filaceii  in  watei 


I'c  passed  tliroiiirh  sti 


•es  or  with  al.solute  alc.diol  ami 


pi-cvioiis  tostainin-'.    Tl 


•on;,'  alcohol  (to  remove  the  „ii 


Mil-l.ic|.s,n  solution  „fXiehl.     The  secti 


ipi'i'atiiiv  of  (il)°  ( 


eniost  satisfactory  dvi 


or 


'li'  I'l 


or,  1 


ftl 


lis 


irlit  lioi.rs  in  the  thermostat  at  37°  ( 


c  inconvenient,  tl 


ons  are  left  for  two  I 


|ffiN|M'nitiir 
lilt-  fuc 


ISIII. 

iii'iitiirv  I 


The  t 
Jiood  dec,, I 


r  for  t 


•  , "■     '  -  or  lor  twentv-f 

issiie-elements  and  the  hacilli  an",  tl 


ley  may  he  stained  t 
nty-foiir  hours  at  tl 


lours  at  a 


or  SIX 


lll'Kl 
llllSt      I 


l^lnii'tt'd.  tllC  till) 
J'  is  licst  t 


hvdrochl 
•full 


orization  solution 


le   car. 


oric.  1, 

y    watched,   as  t 


is  the  ord 


le  room 


in 


m.  ilestill.  :](),  alcolud 


HIS  Stained  deeply 

imiry  acid  alcohol  of  the 

'_")•     The  decoloriziiijr 


--,-^^:^z^^:zzt:i:tXj-^.^..^^ 


'  I'emove  tin 


rici'iilcij  pink-  tint. 

[h'l'fiit.  ii(|ii,.,,i 

>iii  ( 


sectK 


fi.«  from  the  acid  alcohol  while  tl 


osincr  their  stain. 


coiintcr-stain  is  tl 


'cy  still  ret; 


wlor  trniii  the  t 


■'■^  .solution  of  m,.tl,ylenel,l„,>.     Tl 


<'»  used,  the  most  desirable  1 


issue-elements  and  stains  tl 


lis  removes  all  n 


teini 


iin  a 
r  a  '1 


'mainiiii'  fucli 


icm  a  delicate  blue.      The  tiil 


uher- 


!    If  J 


9() 


AMERICAN  TEXT-ROOK  OF  DISEASES  OF  CHILD  RE.. 


;  J 
I 

7 

I 


HJ 


c-le  biicilli  are  stained  a  brii;lit  red.  The  sections  are  to  be  dehydrated  n  ,,!jso. 
lute  alcoiiol,  cleared  in  oil  of  cloves  or  preferably  in  xylol,  and  mounted  h.  xkW 
balsam.  It  is  best  to  examine  with  an  oil-immersion  lens,  althoiii,'h  if  tli,  iii,;.,]]',' 
are  numerous  they  can  readily  be  made  out  with  a  <,'ood  hijrli-iiower  i!\  !(.,;, 
(Zeiss  3,  or  Leitz  7).  Tubercle  bacilli  may  be  demonstrated  in  tiss  ,.<  1, 
means  of  the  rapid  method  used  for  staininif  them  in  »])utuni,  but  the  rcsuls 
are  very  unsj.tisfactory,  owing  to  the  distortion  of  the  tissues  residtii,-  tioni 
the  action  of  the  heat  and  the  stronj^  acids. 

The  bacillus  is  aerobic,  and,  altliou<:h  somewhat  dillicult  to  cultiviiic,  nuiy 
be  grown  ()ii  blood-serum,  glycerin  agar,  or  even  on  potato.  The  colon  hsfMi',; 
dry,  grayish-white,  scale-like  masses.  In  the  growth  the  bacillus  forms  coitiiii, 
soluble  product  or  toxines,  which,  if  introduced  into  the  body,  produce  Icsiuns 
similar  to  those  induced  by  the  bacilli  themselves. 

The  bacilli  are  tolerably  tenacious,  and  retain  their  virulence  after  ficczirir 
•  desiccation,  and  salaison.  It  is  stated  that  the  bacilli  have  been  fomul  alu^! 
after  burial  of  the  subject  for  two  years.  The  combined  action  of  drvncss  iq,,] 
exposure  to  air  is  stated  to  diminish  the  virulence,  but  tuberculou's  spiiiiiiii 
exposed  to  the  air  for  from  fifty  to  one  hundred  days  still  retains  its  viinlcna. 
The  bacilli  are  rapidly  killed  in  a  few  minutes  by  moist  heat,  as  in  lioijiinr' 
<lry  heat  is  nmch  less  effectual.  The  bacilli  are  found  in  variable  nuiiiln.ns  in 
all  tuberculous  structures — the  acute  miliary  nodule,  the  caseous,  fibrous,  ainl 
fibro-caseous  nodules.  They  are  most  abundant  in  rapidly-growing  riili('idM 
and  in  the  old  ulcerous  lesions  of  pulmonary  tuberculosis.  'They  ar(rscantv.  as 
a  rule,  in  the  more  chronic  tuberculous  processes  of  glands  and  of  boiu's,  ami  S,, 
the  lesions  associated  with  extensive  caseation.  When  not  easily  demonstmlile 
by  histological  methods,  inoculation  in  animals  may  alone  determine  the  tuber- 
culous nature  of  a  structure. 

Outside  the  body  the  bacillus  has  been  shown  to  be  a  very  widely-dis- 
tributed organism,  the  nutuber  in  any  locality  depending  upon  tli'e  nuiiiliOTof 
cases  of  pulmonary  tuberculosis  and  the  carelessness  or  thoroughness  with  wlndi 
the  sputa  of  infected  individual.s  is  destroyed.  In  an  ordinary  case  of  piilmu. 
nary  consumption  countless  millions  are  thrown  out  daily  and  scattered  widely 
in  the  sputum  dried  as  dust.  Cornet  found  the  dust  of  hospital  wards  anil 
places  occupied  by  tuberculous  patients  to  be  infective  in  a  number  of  luses, 
Thus  of  118  samples  of  dust  from  the  Avards  of  hospitals  and  I'ooms  oconpieii 
by  tuberculous  individuals,  40  proved  capable,  when  inoculated  in  animals,  .,f 
producing  tuberculosis.  The  infectiveness  of  the  dust  of  the  medical  and  sur- 
gical divisions  of  a  hospital  was  found  to  be  in  the  proportion  of  TH.ti  to  U'.'.. 

(r)  MoDKS  OF  Transmission.— (1)  Expcnmnttal  Tuherculoxis.—.,  uli , 
our  knowledge  of  the  disease  has  beenderived  from  experiiiumts,  and  w^  mre 
to  Villiman  the  demonstration  of  the  infective  character  of  all  tuberculous  jini- 
cesses.  The  receptivity  of  animals  varies  very  much  :  the  ral)bit  .-(id  (ruin.;!. 
pig  are  particularly  susceptible:  dogs  and  cats"  are  very  resistant.  Ilovincs  imv 
very  susceptible,  and  one  of  the  most  important  facts  in  the  eti(dogy  of  tlit 
disease  is  the  fre(|uency  with  which  the  disease  occurs  in  them. 

Subcutaneous  inocidation  of  tuberculous  material  in  a  suscc|)iiMc  aiiimid, 
as  a  rabbit  or  a  guinea-pig,  is  followed  in  a  short  time  by  the  prmluction  ofa  i 
little  nodular  growth,  which  softens,  and  even  ulcerates,  and  whi(di  lu  tinic  iiiav 
be  absorbed.  The  corresponding  lymph-glands  swell,  tubendc-  ilcv(dii]i  in 
them,  and  then  caseate.  The  animal  dies  in  fnmi  six  weeks  to  ihne  UKinilis, 
Tubendes  arefoMn<l  in  the  lymph-glands,  and  there  is,  as  a  rule,  gco'Tal  tiilnT- 
culosis  of  the  organs.      The  most   satisfactory  method  is   the   in  culatiori  i'' 


:^ 


> 


ldrk:. 

tlriited  1.  ,,!js„. 
ounteil  1.1  xvld! 
^'liiftlh'iiacilii 
[lower  (l.v  |,.,i. 
I  in  tissues  i,y 
but  tlic  i|.si,|('< 
rosiiltih-  iv,„„ 

eultiviiic,  iiiiiy 
e  colonics  f;,n!, 
s  t'oi'ins  ccTtiiiii 
[irodiicr  lesions 

after  f: cczin;, 
-'II   t'oiind  alivc 

of  (Irviil'SS  ;.||,1 

culoiis  spiitiiiii 
■*  its  viniK'iieo. 
as  ill  iioiliiii,; 
do  iiuiiiIrts  ill 
s.  fibrous,  mill 
*viii,<r  rillicixlts 
^are  scanty,  as 
'  bones,  and  in 
•  dcnioristmlile 
line  the  tuber- 

'ry  Avidely-dis- 
:lie  numherof 
ess  with  whidi 
:3ase  of  piilmo. 
altered  widdv 
till  wards  and 
liber  of  cases. 
)onis  occiipiid 
in  aniriials.  'if 
dical  ami  siir- 1 
Tli.i;  to  U'.'.,  j 

(/.v. — .\  iic!; 
i.  :illd  "ivs  iiup  1 
Jei'ciiloiis  jini- 1 
t  i'lid  iiiiiii";!- 
liovincsarel 
tidlogv  of  tlie 

ililile  animal, 
oduction  III' a 
I  in  time  may 
's  devcliip  in  j 
iiree  iii(iiiili>^ 
•eneral  tiiliiT-  j 
I'M'ulatioti  of 


""#•1 


If-  -  i. 


';>K 


.^'N' 


•%. 


^K'.yj- 


•ty 


•rtvl*  \\\ 


,{   • 


Mh. 


^■^ 


•* 


'^::.'tt^ 


-)e5> 


*!i 


PC, 


if> 


UlM 


;m 


'''h 


•I',.  „■»  'Vi. 


r\.v 


;.^^ 


'  •^-•ifM NV.«f  ■"-..• 


•  »•.-  ^  •..«.='  .11',' 


«'-; 


'^••^'^'^ 


•  •  ».•   » .  ••••j 


i^  '^ 


'r 


'Ti 


-^. 


/T 


-< 


-i 


\, 


^ 


xy% 


i-? 


-t 


V 


i;ii 


--1^ 


>v 


matei'iiil  into 

iieiiii.     The  d 

MdchM  in  tl: 

I  fiiiiiciaicd.     ill 

•  C'litiiviy  loca 

I  iijc'i'tfil  into  t 

i|fve]o|iiiient  ot 

If  a  iiiruiT  (|ii; 

Ik'liirc  I  lie  tulii 

Tlic  triin.siii 

|4' f)iu.>iiii,'  anil] 

ill  sdiiie  iji.st 

liave  tiillowt'd. 

|al>o  lircii  (leinoi 

|ol'  tiiliciciiious  ( 

(2)  Uiinh't,, 

"Cil  ;is  follow 

I  Mil  luiivnt  to  ol 

Irtiate  to  tlio  tra 

|!v|io  of  tissiie-.soi 

|iiiial  infection. 

Coiiirt'iiital  fii 

Jiirca.se  of  (.'Jirii 

jiiii'  muiitlis  old, 

]tiiiM,  born  at  ten 

iiiw  were  fonin 

iMidi  were  .showi 

|!iik'rciiloii,s  motlic 

|c«ys  of  the  jmla 

m^  tlio  fdctii.s,  be 

liviT,  peritoneum, 

1  the  child  bon 

llmr  and  spleen  v 

In  all  of  the  a 

liraiisiiiissiion  is  not 

Ifiamita,     Tiibercn 

Jftli'ii'teil  an  ins(ane( 

|k'«;rlifli  ,))■  niiitli 

siirf-iLTs  of  the 

|l!"'  fliaracfei'istic  h( 

'■''  'III'  placenta  of 

■i!'''ltliat  tlieanmii 

■'I'l-iiiiiea-piir. 

'Iit'rcarcsevei'al 
Iftoiiii).  ulnVl,  ind 
Iffircseiicc  „f  ,„.t„,, 
ft  K'tiises  lioni  of  tl, 
A  nio(lili,.,i  view  ( 
I*  tliat  111,,  virus 
ri'l"|)  until  MMiie  ti 
""''«•  of  cases  of  fi 

/"■ijlmvcal.vadybc 
""'wulusis  in  the 

7 


I  1    ■  '  f)7 

i;iateii,il  into  the  antnvi'n,.  .1        i 

Wore  the  tube  v  S  •''''''^'  ^'"''  "'""'"'  ><'av  di  en    -  \  '"  *''^'  ^^P'*^^'"- 

TI.etn.n^:-i,^-;-.;;;;^^i^  to  ti.e  ,..,i;';.:    '^  l-'-ul  infection 

pH"l  MS  tollou-.s:   AVliile  in  ■,  f,.u- ,.     ""''"*  op'nion  on  this  noinf  ,„..     7 
,fr'iii  !-'.it.nt  to  offsnnn-r   i,     i,  '*"'"  ^'^'^^''^  tuberculosis  is  trn        .     7,''^  ^^- 

,^|.of  rissue-soiUavoml  et  du.r\''''''*'  ^'"^  «f  "  'lisi^     i  n    J '^"7"^^ 
^iiitai  infeetion.  '"  ^^'^  ''ovelopnient  of  the  disc-  so  i  ^•;."''^''  ^ 

Congenital  tuberculosis  h,s   b.        .  '"''  '^  "'-■^•^- 

licease  of  ('|„Tin,i  tber    «  ^''"  o^'-^'^rve.l  in  some  siv  <,.-    ■   , 

wiiieMvere  found  -it  i„l  "°^'"^'''  •''^^«l  "n  the  nintl   ,  ,    '"""  '''« 

'■'"ifc'i  iiii  instance  I., ..  ,.  '"'•^"'f'l  '«  very  rare      T  <.!,,.        ,  '"°"«''  "le 

""■|'i<'^c'iHrof  ,„.t„,i  f,  L    I     "'.^  ^"'"^  'nay  be  present  in    \     V  '''''"'""^ 

S  Sir  "5&^ 


I  u.iuiH.,,  legions  10  ivliitl,  ,|,„ 


98       AM/'JRICAA^  TEXT- HOOK  OF  DfSKASKS  OF  ('IIILDni. 


biuiilli  would  not  l)e  likely  to  he  coiivcved  in  iiccidcntMl  ini'cftion.  Tl 
natal  development  he  re^jiards  as  analoLrous  to  xiipliilis  lirrnlltiirin  fardn 
Hii^jj^ests  that  the  actively  irrowiii,:,' tissues  of  the  eliild  restrain  or  inl 
development  of  the  jj^eiMiis. 

There  is  no  evidence  to  show  tliat  a  tuherciilous  fati 


Ml  it  the  disease 


'r 


lei'  can  dii'ecii 


recent  article  on  '*  llereilitv  in  Ti 


le  experimental  evidence  is  also  ne^rative.     (Jiirtii 


■  l'M>t. 

.^nlJl,. 

II  t!i, 


M'aii-- 


le 


ilierciilosis      IS  the  most  important  f"iiii'ilii , 


'lUll 


ti(tn  made  to  the  sni)Ject  of  late  years)  found  that  in  rabbits  and 
with  artificially  induced  tuberculosis  of  the  testes,  and  whose  semen 
l)acilli,  the  emlir  us  were  never  infected.      On  tlie  other  liand,  of  ( 
f^niiie;i-piifs  wliich  had  consorted  witJi  the  tii1)erculoiis  bucks,  5  presentcil 
tuberculosis,   and  of  o!»   female   rabbits  under   similar   conditions    ]] 
infected. 

In  su])]K)i't  of  the  vi(>w  that  tuberculosis   is  hereditarv  irrcat  sti 
'latiirallv  on 


•'"iilaiiic 


''CCailu; 


the  fi 


■eiiueiicy  witli  which  a  history  of  the  disease  is  met 


the  par-nts.      'i'lie  estimates  of  various  authors  on   this  point  varv  frmn  |ii 
;■)()  per  cent.     Of  427  cases  at  the  Johns  llo))kins  l[os])itaI,  there  w 
in  which  'Ir-  mother  was  affected,  ")2  in  whieii  the  father  had  had  ti 


and  lO.")   in  which  sister  or  brother  had  had   the  di,' 
children  and  relatives  of  tuberculous   individual.- 


:ease.      '{'he  fact 


eiT(,l||y 

uliciviilii> 


are  more  directly  c\ 


contaLUoii  than  otiier  individuals  I'cnder  it  dillicult.  as  Fa;;ire  rema'rk> 
fi  clear  line  between  liereditv  and 


lliat  th./ 
I"  ili'an- 


accidental  infection. 


(•5)  Jihh'ii/'ifiifu. — This  is  not  verv  common  ii 


th 


1  man.  as  the  skm  ( 


a  very  siiitabie  sod  for  the  development  of  the  tubercle  liacilli.      T 
infecti'in  is,  !i  iwcver,  seen  in  persons  whose  occiqtations  In'iii'f  tl 


I'K'S  iKit  oil,.;' 

lis  iiiful,.  ,,j' 

icui  ill  co'iiai! 

omv  aiv  naitici;. 


Avith  dead  bodies  and  animal  products.     l)(>monstrators  of  aiiat 

larly  su'ojcct  to  a  local  tubercle  on   the  linger  or   ba(d<  of  the  ri;niil~i| 

called  post-mortem  Avart.   rmnii-a  iirf/YK/ciiicn.   the  "•  lichen  "  till 


HTc 


Oeiinaiis.     Only  in  very  exceptional  instances  is  this  followed  by  seridii-^  yi'<v.]< 
Cases  have  been  reported  of  infection   from  the  l)ite  of  a  tuberculoii- 


inoculation  from  a  cut  by  a  broken  s[)it-cup  and  the  puncture  of 


niic  needle. 


Iiere  is  no  re 


■liabl 


In  tl 


servalion  of  the  traiism 


losis  by  vaccination. 

have  iiecn  inoculated,  the  infection  in  these  cases  1 


issloii  of  t 


|iali('iit, 
a  liypiiiiiT- 


performance  of  the  rite  of  cii 


ilhcVi'll- 


■cuincisioii  cliiMmi  Htbn  the  p 


in  the  operator,  and  occurs  in  connecti)n  with  the  lial)it  of 
by  suction. 


)einjr  associated  wiiji  ilisca- 
cleausiii--  the  \\,n\U'] 


(4)   7 


raHKiiuxx/ii 


tl   hjl   TitJiithiti 


III). 


riie  expired  air  of  tubercii 


OII> 


lialicm- 


is  harmhss,  but  the  sputa,  dried  and  widely  diffused  in  the  form  of  iliist.  chu- 

stitiite  one  important  medium  of  transmi.^sion   in   the  disease.     The  invi'.«ti-| 

Rations  of  Cornet  have  shown  the  greater  infectiveness  of  the  dust  dl' Incalitii- 


fre(iuented  by  patients  with  ,,ulinonary  tul)erculosis.     The  f 
the  <li.sease  is  met  with  in  the  lungs  and  in  the  bronchial  gland 
e.\))lanation. 


rei|Ueiicy  with  wiiidij 
liinls  lici't'  its 


In  institut'  ns  the  residents  of  whicl 


air  aiK 


I  exe 


1  are  restricted   in 


tl 


rcise.  as  m 


iiid  convents,  the  death-rate  t 


very  much  higher  than  in  the  general  jiopiilation.      Cornet  found  that 


(>  religious  communities  more  than  three-fourths  (d"  the  dcall 


le  iiiaiirr  n[  tiv-ii 
rom   tiiliii'ciildsiv  i- 


III  <u\w: 


IS  were  iliii'  M 


of  tl 

this  disease.      The  mortality  in  prisons  from  tuberculosis  is  from  I 
cent.,  while  in  the  general  community  it  is  not  more  than  1 ")  per  (ciif. 
lias  brought  forward  evidence  to  show  that  the  distribution  of  t 
one  of  the  wards  of  the  city  of  Philadelphia   is  more  particularl 
houses  in  which   individuals  have  died  of  this  disease.      Tl 
striking  local  epidemics  of  tuberculosis:  thus  Marfan  giv 


tu  .'ill  |lll' 


iii'civiildsi.-  nil 


lere 


itli  certa 
alsd  .sniiii' 


cs  an  in-taiiceiit  a 


f  PWiilly  with  the  en' 


TVBERCir.OSIS. 


Ii|:|«' 


orifi 


9,9 


IKM 


iicivjoiiu'il  ill  l!S7,s  I 


'iidh'  VCllfil;,r,.(l. 


0C'CI1|H(.(]    I,v  twciif 


i:it  iiiMiut  tlio  fl 
I  mil  Inratlicd  tl 
i't\v(vii  1,S,S4  and  1,SS!» 
A;:.utist  tlic'so  fjicts.  1 


'.y  '\v(,  c^oiisiiinptivcs.  wlio  f 


y-i\v((  otnjdoyoos.  wli 


our  indiscniiiiiiMtc 


Tl 


'"•  ■'^oven.l   vers  ciikI,,,]  ,„„j 


10  !iir  cliaiir,,!  \vitli   tlie  d 


'•■  ciiiploveos  arrivfil  at 


tliirtc 


on  o 


f  tl 


•i"<t   I'Mist'd  Itv  tl 


an  carlv  I 


io\V(n'('r. 


loso  poi's.ms  fell 


10  iiKMiiin"-  float 


I'o  tlic  Stat 


M|.tu-os,  as  at   IJnnnpton,    in    I.-ndon/tl 


on 


lontS    lliill     ;,t    I 


viotiiMs  ro  tnlicTcul 


loiir 
iin<r. 


•  ISIS. 


farkcd.      Dottwcil.T.daiiMS  that  at  I 


10     (lot'toi'j 


'iiiil   niii'scs 


crculosis  has   I 


lis  institution  in   Kalkcnsto 


ilio 


•iruiii,--i.-s    lias      lOt'Il  (•()lifi-i,.t,„l         i\      ^1  , '  '•' 

l^ins  hospitals  /;>  :!!;''';     <*"  fl'<\"tlior  hand,  M 


■'pitals  tnhoroiil 


osis  IS  o.vtrci 


irfa 


'"■I.V  <ro(|iK.iit  in  th 


"I'ltals  for  fo,,. 
aro   rarely 
in  no  caso  of 
"  ■''tatcs  tliat  in 


nnii.los  tlio  lay  0(,i.tinrri.Mt.     At  tho  lloJt      v'    ,      ',"  '''^'  i'ttondants  and 
cattackod  with   i,i,tl,i".    I  ...  ^."'  ^''''^P'tal  iNookor  half  of  tho  Mfi,„„l...,  , 


with  jihtl 


laiiy  the  attondants  in  th 


ii.^is,  and  he  not 


I'  iiiodical  wards. 


f  tl 
"  -^igiiificiint  faot  that 


ic  attendants 


It    IS 


liariicu- 


•m,      j,      _.      .  ■•  ""■   '"^'iieai  wards.  !■..., m,. 

s '"''<"'•'•"'<>»"   niotlu.,'  and   hVi'l'lnl'd  '!T\Z^J!  P'-'i't'eularly  intimate,  as  I.etween 
«■  then,  are  fi-nires  whieh  ind  1.''^"  "''■'"  '"""^  '''''^''-      '"  f''<'  J^'ttc" 

m  be  coiniminioated  by  in-esti,.„  of't  ,l,e  '  ,  '"''      '"'"'   ''"'^  i'lfo.'tion 

^'-nrnportaiitproIdeinsVelatest     n^ot  "'!'  "''''"■'•'••''■  '""'  ""^'  <-»•  the 

f:^!"'""""^^''l.v.'  it  has  boon      i  <•         I     ,       ''''  ''"'  '"'"^  "''  f"'H'n.ulo„s  eow 
.V.  oven  wlK.  the  disease  I  ll  ;^-;'-fated  that  s.ieh  n.i,k  is  ii.ft,:: 

n>iio(^neeossa.j  that  the  nddor  shoid V  '  '  "''f  "r""  ':"'"'"'•  "*"1  f'"'* 
AelMcil.  may  be  pivsent  i„  ,!„>  mik   '•  ,  ^''"'-^^  '"'^  ■^'"'^vn    that 

Ti-l:H..orof  infeelioi,  (Von,  this  Zt^l^^  '^  ""  ^"'---I"'-  manunitis. 
.'..sinitan-  inspeetion  shunid  be  made  ,.•,,!!"'  "  '''7  'I!-''"''  "'"'  ^^^"•>"- 
is'i'iiexponmoiits  made  with  the  milk  """'•  '^  "^•(■•''•^.•n'v.  im.eii- 

,    "'•"  !'<'roonta-e  of  tiiljoronlous  animals  in   fl       i   • 

.v.y  inaeh    la,-.of   than   has    been    si  ^       ^':;;,  •^";:'^--^''''l^"^  of  our  eitios 
If'rlnrixo  numbers  aro  not  available       It     ,.      i  "!"""'  '"  ^'''«   '•"""ti'v 

[«Tent.  of  the  .lairv  stock   in  the   R    ,         T^'  •'^"^''''  "'"^  ^•■"•"  1<»  to  If, 
!f"W'Iv;'.  low  estim'ate.  "■^'^■''"   ^^^''^'^^  ''^  tubereulous.     This  is 

The  vinilence  is  retained  in  the  er  i- 

l-b  the  presence  of  the  baeilli  in  tin' nnil'Ir:  1-  t\  l""'''''"     '  *"'""  ^•"'"'itio.is 

'™">^"^"l-     In  some  instances  the  -  •  str        ,  ""  ''  '""  ""*  ''^<^"'»^  ^on- 

A-.  conditions  of  the  tissue  1,.^;  to  ,  T  """•>',  ^'^^^''^.^  ^he  bacilli;  in 
'  tl-e  .seed.  Experimentallv  it  Is  ""Vsb  ''?,''^'  /"  ^''^'  development 
i*<'Mns  not  nocessarv.  and  iZt  mi  of  ^7"  "'  '"'"''  "^"  *''«  ■"t'^«- 
f  "^ 'l''""^'l'  ■•.  normal  m„eosa.  I'os  vtii  '"T^''"'''*'  -''•""•«  '""v  take 
■■■^'-i^m.hildren  finds  hore  it    ex    t     0,^1      '^li"^"«T  of  mesenteric 

I*.  unv,.ver.  is  only  marke.l  w he  tdi  :;"'''  ^'  ^•""fi'^'^'^^-l-  The  viru- 
J  •'•"  ^)o«n  that  the  flesh  of  tuln.r  o  s  " m  ''  -'T  ''''''''^''-  ^^  ''"s 
|W4J,owevcrJnaseriesofex-,)er  11  L^^^^  nifoetive  to  .jruinea-pi.s. 

[  '".ity-oiie  cases  with  ffoner  d  ,  e  •  I  •  """  ^'"'^  '^''  -'"''"^^  •>*"  ^''^  •"-'le 
h-f  ..inea-pi.s,  ..nlAnco  prX;;i  ;;:!::ll;::'':..'''-'^^'^^'''    -^^  the  perito 


[til 
llnlii 


HTCUloslS 


I'^Pwiiilly  with  tl 


"vcnroxs  lvkmikntimj  [ 


M'KCTIoX. — I 


'0  environment  of  in.lividuals,expl 


(\)C 


>nin;tL—Thefio,  deal 


nil  111  a  irreat 


msr 


measure  the 


■M  I 


I 


^^ 


100    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

frequency  of  tlie  disease  in  certain  localities.     'I'lnis  one  of  the  most  iiii^    itant 
is  residence  in  tlu?  larj^e  centres  in  wiiicli   many  j)eo|)l(!  are  crowded  t'.    ili,,|- 
Tlie  death-rate  from   tiiiterculosis  is  very  n)iicli   hi^lier  in  towns  than    n  t|,(. 
country,  and  a  very  consideratde  share  of  tlie  hij:;h  infant  mortality  of  eitn  s  j^  to 
be  attributed  to  it.      Not  only  is  the  air  of  the  larj^e  towns  less  pure,  !;,u  th,; 
cliaiices  are  very  much  j»;i'eater  that  the  dust,  blown  in  all  directions,  hi.  hhI; 
it  the  i^ernis  of  the  disease.      The  inhalation  of  impure  air  in  certam  uvy\\. 
pations,  whicli  in  adidts  is  an  important  jiredisposing  factor  in  pulmonar\ ml,,.!-. 
ctdosis,  does  not  prevail  to  any  special  extent  in  children.      Climate  in  itsdj' 
does  not  influence  tlie  conditions  mat(M'ially,  Imt,  as  a  I'ide,  the  disease  ,s  iii(|iv 
common  in  the  temperate  iTgiotis,  hirjfely  because  in  these  are  found  the  hirir,^; 
collection  of  human   beinjxs.      Soil  and  locality  have  an   important  inlliuMiiT 
cold  and  dampness   increasinj:  the  personal   liability  by  fuvurinji;  the  ilcvcjoi,. 
ment  of  catarrhal  affections.      There  are  fewer  caso  of  tnl)erculosis  aiiil  fewer 
foci  of  infection  in  rejiions  such  as   the  Alps  and   in  elevated  ])late:iii\  :i>  in 
Mexico,    but  altitude   itself  does    not   confer   immunity,  and   there  aic  luimv  j 
mountainous  regions  in  which  the  itdiabitants  are  much  affected  by  tuliciviildvis. 

More  im)iortant  than  these  are  the  factors  rebitiiii:  to  personal  envirniuiieij, 
as  of  the  dwelliiiirs.  The  constant  i)reathinir  of  a  vitiated  air,  as  in  tlusiDnil 
crowded  rooms  in  the  tenements  and  narrow  alleys  of  our  larj^c  cities.  ;uiil  ihe  | 
absence  of  siinliLrht,  are  two  of  the  most  important  predis|)osinjf  I'lcineiiis  m 
tubi'rculosis  in  children,  'i'liese  iidlueru'e  infection  in  two  ways:  lir>t,  l,v 
favorinir  the  distribution  of  the  bacilli  ;  and.  seccmd,  by  loweriii;:;  tlie  uiitininii  j 
of  the  individu;d  and  leadinix  to  conditions  favorini;;  the  entrance  of  tlic  haeiiii  j 
to,  or  their  develo|)ment  in.  the  !)ody. 

(2)  Jndiridwtl  I'rfdispnsifioii. —  From  the  time  of  Hippocrates  it  liii<  Lein  | 
thoiijxht  that  there  was  a  certain  conformation  of  body  which  rendered     ,  iinl] 
vidual  more  prone  to  the  disease.     Ills  words  are  :   '"  The  form  of  bodv  peculiar  | 
to  subjects  of  jihthisical   complaints  was  the  smooth,   the  whitish,   that  ivsw 
blinj:;  the  lentil :  the  re(hlish,  the  blue-eyed,  the  leuco-phlejimatic  ;  and  tliutw:; 
the  scapulic  havinj!;  the  appearance  of  wings."      In  children  it  may  b(!  siiiil  that  I 
the  build  and  type  such  as  here  described  is  certainly  more  pnme  to  tiilnr. 
culous  affections.      Two  types  of  conformation  have  long  been   recojiiiized  as 
predisposing  in  some  way  to  infection  ;  the  tuberculous,  with  bright  eyes,  oval 
face,  thin  skin,  and  long  thin   bones,  and  the  KcrofidoKi^,  with  a  lieavv  fiLmie, | 
thick  lips  and  hands,  opaijue  skin,  and  large  thick   bones.     JJut,  as  in  ailiiltj, 
well-developed,  healthy  infants  and  children  nmy  become  subject  to  the  disease. 
In  addition  to  the  conformation  of  the  chest,  the  respiratory  capacity.  tliereli-| 
tion  l.'Otween  the  volume  of  the  lung  and  of  the  heart,  a  relatively  small  litart 
Avith   narrow  arteries,  and  a  })ulmonary  iirtery  relatively  wider  than  ilieanitai 
(IJeneke),  and  relatively  Iarge-size<l  vLscera.  have  all  been  brought  i'oiwanlasj 
causes  ))redisposiiig  to  tuberculosis. 

Among  others  which  may  be  mentioned  is  race :  the  n(>gro  scciiis  iiiniej 
liable  to  the  disease  tlian  the  white  races,  and  it  is  stated  that  the  llebiuws| 
possess  a  relative  immunity. 

Mori'  important  in  children  are  the  local  conditions  influeiu'ing  iiifeeliim. 
Acute  and  clironic  catarrhal  troubles  of  the  throat  and  upper  air-|ia>sai:es,  ami 
of  the  lung,  undoubtedly  favor  infection,  either  by  allowing  the  freer  (iitiaiii'e| 
of  the  germs  or  by  weakening  the  powers  of  resistance.  The  ird'cctiiniMlisoasos, 
particularly  whooping-cough,  measles,  and  influenza,  act  probably  in  this  way, 
while  small-pox,  typhoid  fever,  and  syphilis  influence  the  condiiimis  rallierliyj 
reducing  the  power  of  resistance.  In  institutions  the  frequency  witlnvliidi 
tuberculosis  follows  the  infectious  disorders  is  very  striking. 


TUHEItCULOSIS. 


101 


Ul  k)cul  iflTocf  ons  of  tlio  l,u,.s  winch  pro.lisposo  to  tuberculosis,  haemoptysis 
riich  >vas  regarded  as  an  nnpo.lant  cau.o.  is  now  thought  to  he  u.  inES 
r:,.lK"j  of  the  (vx.stence  <,t  th,.  .lisease.  Such  disorders  as  dilatati  f  " 
.".Hi,,  and  pleunsv  also   heighten  the  liability  to  infection,    tho    '  o 

The  subjects  of  congenital  or  acquired  contraction  of  the  orifice  of  the 
plnHU.ary  artc.T  usually,  as  is  well  known,  d,e  of  tuberculosis.  W  to  e 
,H.  .im.ent  ot  the  disease  uu.ny  subjects  show  a  inarkcl  a.uenda.  an.l  a  m  e  ! 
«.hiy  cl.hn-o«ts  oilers  ia vonn.  conditions  fbr  the  developu.cnt  of  this  aft  S 
Ii,.«,sc  ot  the  st.uuach  and  tntesttnes,  particularly  chronic  entero-coli  is  in- 
crease the  susceptibdity  to  infection.  i^^iius,  in- 

B1..WS  and  contusions  favor  in  some  way  the  development  of  tuberculosis 
.rncularly  m  ehddren     ,n  ^vho.n  spinal  caries   and  hip  disease  may  ?    1  w 
jH  ...jury  ;  less  otten  does  ti^auma  play  any  part  in   pulmonary  t,.b  tcuI  s 
IkTC.  too   may  be  mentioned  the  favo,.n.  influence  of 'ope,.,  t  ion  :  resec         of 
a  n  KMTulous  joint  ,s  occasionally  followed  by  an  acute  infection 
iJliv'betSiSr'"'^''''"''  "'•  '^"  ^""^I'^i''''^  ^vhieh  inHuence  it  the  fbllow- 

(.)'Jn  a  few  cases  the  disease  is  directly  transmitted  from  the  mother   and 
appwu's  in  the  child  at  birth.  uiuiuei,  ,inu 

{/')  The  primary  tuberculosis  of  the  bones,  joints,  kidney,  spleen,  liver  etc 

l.l?in;;il;;?;?'S'^"  "'  ^^^  '^'  ^"^^^'^'^  '^  rost-f«.tal-through  the 
(.)  Heredity  influences  the  soil.  All  are  Uihcradizahh.  to  use  a  French 
expiessum  ami  very  many  of  us  actually  become  infecced.  Whether  or  not  "he 
md  .lovelops  depends  finstly.  upon  the  character  of  the  tissue-soU  and 
mnAh    upon  the  exi.stence  of  special  favoring  circumstances.  ' 

(/      ...munity,   a  relative   condition,-  enjoyed  chiefly  in   consequence  of 

.nl:o.-.ted  fssue-resistance,  IS  lessened  by  all  circumstances  which  depm"  nutr  - 

on,  such  as  ba.l  air,  bad  food,  and  imperfect  hygienic  surrounding.s^     Next  to 

.1.0  jro,.,..  a  vulnerability  of  tissue,  however  brought  about,  whethe    congel.  ta' 

o.:,n,,.,red,  IS  the  mo.st  important  factor  in  the  c^^iology  of  the  disease^ 

(•])  Ihr  Relahms  of  Tuhn-ruhsh  and  Scrofula  .-'Vh^  lesions  known  as  scrof- 
«lo.,s  .re  tuberculous   and  .iue  to  the  development  of  the  hanlluTZlrlnhs^ 
h-"a   t,,e  term  scrofula  IS  now  almost,  and'may  well  be  entirdv^  aS^^^ 

o,>gh  the  so-ca  led  scrof  uous  lesions  of  glands  and  bones  and  skin  aJe  £   h   v 
^     ongui,  yet  1    has  been  shown  that  their  virulence  is  not  so  extreme  as    S 

otu  erculous  products  in  the  viscera,  the  latter,  accordin/tcA    o 
'...,.  when  .njected,  both  guinea-pigs  and  rabbits,  the  fbrnu^.^mi;.;,-  "a! 
fi-'s.    J  his  .-orresimnds  with  the  more  protracted  course  and  the  .  „.,•,.  f..,. 
;™.nat,ou  of  the  so-called  scrofulous 'aflWtio^r   It  h^^^^ 
-.  0  ,  n.  abeivulous  manifestations  are  caused  by  an  attenuated  v"        n 
r  lias  been  made  by  writers,  particularly  Marfan,  to  show  that  th,>  scrof,  lo" 

-;:;!:;::  ;:;rb^';h;■::z::^:;;■s^^     --^ "  -'--^  -  p»!-- 

•.,  uuL  tilt  cMutiKo  Toi  this  i.s  not  yet  very  slronty 
(')  AxATOjiioAT,  €r^Ami^:s  I'koduckd  by  inii  TniiEKcr p  Bacitw      'n,« 


1 '  111  !i 


II    I  B! 


lOJ    AMHIUCAX   TEXT- HOOK  OF  DISEASES  OF  CHILDliF.  , 


if- 


tojiother.  iiiiiv  fdiiii  liirfjo  infiltratod  amis,  so  that  u  distiiicti 
lit'twtrii   tlic   iioiliilar  ami   the  dilViiscly  iiifiltrati'il    vari 
l>aiiiii;:arl('ii   and    dtlicrs   have    t'iial)lc( 
chaiii't's  iiidiici'd  Iv   the  bacillus. 


on   is  o 


fp 


cllcs. 


Ti 


It'    Stil 


I    IIS    to   follow    acciirati'ly  the 


MIIUlol 


IIIIIIVV 


iii'si-  arc- 


HIS. 


(1)  Tlic  iiiiitiplicatioii  oftlio  fixcil  tissiic-clcinciits  liy  a  process  of  km  ,,,k 


TI 


ic  cells  ol 


the  vascular  epitl 


leliiiiii.  o 


f  til 


onliiiiiry  epitlielimi 


irif. 


tl 

]ar;:e,  rounded,  ciilioiiial,  or  pol_v,iioiiai  cells  wiili  vesicular  nuclei — 


le  connective  tissue  proliferate,  and  jfradiiallv  there  is  produced  f 


iiiiij 


the 


efiif/icliolil  cvWs — inside  some  of  which  the  bacilli  are  seen.      This  rean 
the  fixed  elements  of  the  tissue  would  appear  to  lie  the  nriniarv  elfect 


'-(•1(11 
nil  I 


(li)   iieiicocvtes,    chielly    polvniiclear.   miurrate,  and 


focus  of  infection.     These  form  the  lymphoid  cells  which  were  fo 


to    ll 


e  so  characteristic  of  the   tuhercl 


Th 


accumiilate   al 


rmeri\ 


'Ht    t. 


'lei 


||'iii,i:l.tl 


lllVlSloll. 


Niiiie  believe  that  thev  at 


cv  do  not,  however,  im 


liiini'  denionstrai 

Infiltrated  tu 
faiall  sonit'tinies 

;iR'lllllJ.'S,  for  ill; 
.jiriiiiiided  by  Z( 
iirmliicts  of  the  | 

tlic  bacilli  ca, 
,,iriisii>nally  in  ai 
iui;;.  There  is  r 
;i,ito(l  tubercle. 

.*>ecoiidary  inl 


itlac 


appear  to  bo  successive  invasions  of  I 


lestrov  the  bacilli.     Th 


'I'l'iro  sill,. 


eucocytes  at    the   focus  of  in  , 
many  of  them   undergo  rapid  destruction.      It  is  stated,  too,  that  lal 


little  tubercle  j^rows.  the  leucocytes  wiiicli  siirrouml  it  are  of  the  n. 
form,  or  lymphocytes,  and  that  these  persist  and  do  not   under^'o  tl 
deg 


dear  f 


onus. 


eiieratioii  of  the  polyniic 

(•'))  A  reticulum  of  fibres  is  formed  in  the  tubercle  by  the  fib 


^•t' tiilicrde :   (1 
and  destroy  the  bacilli.     'liMMv  wonliM.THWtli  is  in  reali 

i'i'i'ii'i"ii.  ;iiiilH»Mi-'li  "liiy  be  lim 
ii>  tla'Hti:*'  li'ii,^''  there  i.^ 
i>ion>iiiiii'|,i;,|.H|il'.'ratiiiii  (d'  tlu!  ( 
I'  rM|iii|H4i<»l-  and  lymph 
(!')  Tho'bacil 
i>rill;it!(iii  ;iiii|^iiiW'rcMilosis;  ex]H 
Iprtieiilai'ly  Koch 
|i'i-is  of  the  lun;:s, 
"y  an  I iicrcfl«e^B result  of  a  mi.xeij 
in  the  jirotoplasm  and  in  the  nuclei  of  an  individual  cell,  or  po'ssildv  hv  tliel  i'i)  A  slow,  re 
fusion  of  several  cells.  The  bacilli  are  usually,  but  not  always,  sccii  iii  tiieHiiitlio  formation  o; 
-,'ianf-cells.  There  seems  indeed  to  be  an  antajronism  between  tiie  iiiiiiiboi'an(lHi;ri.v.tli,  and  consti 
virulence  id"  the  bacilli  and  the  giant-cells:  thus  in  joint  and  gland  tulicrciilH^isHMt  in  the  diseas 
and  in  lupus,  in  which  the  former  are  scanty,  die  latter  are  abiiiiiLiui : 


rarefaction  of  th 


e  connective-tissue  matrix,  most 


margins  oi'  the  irrowtli. 


apparent,  as  a  rule 


ill  tl, 


:ie| 


(4)   In  some,  liiit  not  in  all.  tubercles  iriant-cells  are  formed 


miliary  tubercles,  and.  as  a  rule,  in  all  lesioiVs  in  which  the  bacill 


th 


e  giant-cells  are  scanty, 


iiilpial 
1  arc  aliiiinlnii', 


The  tuberculous  nodule  thus  formed  may  undergo  necrosis  and 


or  may  gradiiallv  be  converteil  into  a  coniiectivc-ti.ssue  i 


c;isc;Uifiii, 


iiass. 


C 


iscaiidii 


"I'lllSl 


Ht  the  central  part  of  the  growth,  and  appears  to  be  owing  to  the  dinrt  aiiinnl 
of  the  bacilli.      The  cells  undergo  coagulation  necrosis,  lo.so  tl 


come  irrc 


guh 


leir  outline, 


am 


material  in  which  tl 


1   are  finally  converted   into  a  homotreneoiis.  stnictii 


le  ce 


are  no  Ioniser  distinirui; 


diabk 


aiu 


1  w 


lie- 
I'l'k'ss  I 


iicli  no  IiiiiotI 


takes  the  stain.  .Vs  this  process  extends  involving  several  nodular  tiibcitic 
they  are  gi'adiially  converted  into  nniform  yellowish-gray  masses.  Nd  lijunij. 
vess(ds  are  foiiiiii  in  the  central  portion,  but  the  bacijli  are  iisiiallv  alHiiKkiit, 
J>y  the  union  of  many  of  the  nodular  tubercles  large  ma.sses  ma 
which  may  undergo  either  ("1)  softening  or  liijuefaction  with  the  f 
cavities;  (i')  fibroid  limitation,  leading  ultimately  to  encapsulation:  (.'1)  in  tliel 


sses  iiiav  lie 


for 


irniiitioii 


iiit'ij 


dd 


older  ca 


seoiis  ma.sses.  particularly  when  encapsulated,  lime  salt 


lere  is  necrosis  ol 


the  ti 


s  may  he  (k'po.<itt'il 
ssue-elciiiciits  in  ilic| 


(calcification);   and  (4)  sclerosis.     Tl 

centre,  gradual  hyaline  transformation,  with  great  increase  in  tln'  libroiis  nti-| 

ciiluni,  so  that  the  tiibt  nde  is  ultimately  converted  into  a  firm,  lianl  striictiiiv 


Sometimes  increase  in  the  fil 


riliation  and  caseation  jro  on  toiretli 


\vi 


til  til 


If 


ttl 


IC  |irni|l|('t>  ot 

of  the  ca'si'diis 


production   of  fibro-ca.seous  tiiberch 

f)/(f)(nc  lufi/fnifcil  Tiihcrclc. —  It  was  formerly  thought  tlia 
any^  simple  intiammation  might  become  casecuis.  and  the  identity 
pneumonia  and  of  scrofulous  lesions  with  tiibende.  which  Morton  (Kifi.))  niiiiii- 
tained.  and  which  liaeiinec  laid  down  as  a   fundamental   proposiiimi.  was  For n| 
lung  time  disputed,  ])articularly   by  Virchow.     ^'ow,  the  researches  of  K"cL 


n. 


Foii.Ms  of  tube 

Iciiiiiiiion  ill  infants 

Ikiis  (if  local  diseas 

rill  .siijierlicial  lyii 

I tiii'oiiiitei'cd  in  wlii 

iitlior  that  of  ail  in 

iiiti'iise  infection  a\ 

I  nimingcs  of  the  hn 

i-iKi  liard-and-fast 

.'i':iiiiilati(iiis  occur 

i>l'rniii  three  to  six 

|w:iiiis  there  are  c 

vlinieal  course  is  of 

cvfii  sixteen  weeks. 

I  into  three  groups,  a 

'''I'Vditen  typhoid  f 

'•i'l'i'it'thel'imgs.     'I 

ity  111'  the  ciises.     'I 

wi^urrini;  in  childre: 

ll»'  sviiiptoins  of  a  ] 

I'liis  furiii.  whic.    h 


TinEiivcr.osi.s.  j,,^ 

L.!;';;i:«^:li;tt  s;::?  ;::;;;!;::^!f  ■"  ■■'■  ^^  ;■■"■" : "■"■  '-"•  •»" 

b„:i;:::,;r "— --^^^":^::^t'!;:.s:z^z^^ 

o)  A  slow,  rtju-tiyc  ii,ll,„i„„„ii„„  „„,„,,  „|„„|t  „„„     ,„|,e„ij,  rcsullin. 


e- 


n.  Generalized  Forms  op  Tuberculosis. 

(1)    ACTTK    MlIJAliV    TrnKHCl'LOSIS. 

FoiiMs  of  tuhern.lous  infe,.tio,.  nnn.in,^.  n   vapi.l  ,.„„rse  arc  .locide.llv  morP 
wmon  m  infants  and  dnhlren  than  in  adults.     I'ra.tic.Ilv    tl,  ,o        / 
ki,sono,.al  disoa..  in  a  l.roncl.ial  or  niosonteic  '  !•    d   a     >h     '  '      '^""T  * 

«thor  tlK.  of  an  acute  i,dbcti,,n  witlu>ut  definite  nKuJfbikirM-^ 

-Monso  ,nle..r,on  with  pronouneed  svn.pton.s  V^nni^^^T^lT^^  ^  Z 

h'lv often  tvnhoid  f;.vo.-   m.  fl  t-  ,i-Ciieial  infeclion,  siiniilatmjr 

't\  ut  tlic  ,.;i>os.      liiei-e  nmv  he  niej.t  oned.   iu  -tdditio  n  '■..  ......f  >     J   :■ 


101   AA//:/i/('AX  ti:\t-iuk)Ik  of  dishasks  or  ciiiLinn 


1  : 


vifrrt/'riisr  tuhcrrnlnixc  HnntH/>i<\  is  not  jiciicrallv  recognized,  but  tl,,  (.,;„,, 
(leseril.ed  by  Liiiidoii/.y  and  others  pr.wt.ntcd  «|iiiie  niii'or  tubeiridon.  i,si,;,p 
of  the  Iiin;,'s  or  of  oilier  or;,'iiiis.  willi  rlie  clinical  synintonn  of  verv  i,t,.„J 
infection,  the  severity  of  wliicli  \vas  out  of  all  |)ro|M>rtion  to  the  local  \i-:',u  tu,"] 
to  the  number  of  miliary  jxranulatioiis  found  ;hrou;:hout  the  body.  It  i-  i;„,i|'r)'t 
to  be  due  to  tho  action  of  the  tulierculous  toxine-.  '  '" ' 

'I'he  acute  tulierculous  nieninL'ilis  will  be  dcMi  'led  scjiaratoly.      V  ,.  .||.||| 
here  speak   oidy  of  the  typhoid  and  of  the  pulmoi.arv  types. 

Tiijihiii,!  7'//yy,.,— The  onset  is  usually  insidious,  ai'id  coniinoidy  thnv  Ii^ 
been  an  indisposition  or  slight  cou>.di,  but  prior  to  the  fever  tlu"  c|ii|,|  m.^. 
have  been  in  ,L'ood   health.      The  fever  is  noticed  in  the  afternoon  (U- e\,.ii|,|,; 
and  with  it  there  is  loss  of  appetite,  and  the  child  loses  in  wei,<rht  ";i,|  j,  jj^"' 
less  and  not  inclined  to  play.     A  bnuichial  cou^jh  is  by  no  means  unrniiiiiiun 
but  it  is  to  be  remembered  that  the  disease  may  set  in  ijuit  ■  abrujillv  j,,  .,  ,.|,|'|,]' 
believed  to  be  in  ;."">(!  health.      Within  a  week,  or  oven  earlier,  tliecliil,|  tik,'« 
to  bi'd,  and  the  .symptoms  of  an  infection  are  well  pr.iiounced.      The  t,,ii"iii.  ,>" 
white  iin.l  furred.     The  abdomen  is  distended,  sometimes  painful  on  pir'-mv' 
and  there  may  be  diarrhiea.      The  spleen  is  usually  eiilartred,  and  can  It  in,li|'v 
felt.     The  liver  may  be  also  distinctly  swollen.  "The  j:astro-ii  testiti.il  in,iil,i',. 
with  the  continued  fever  may  be  strongly  au<r<.'estive  of  typhoid  fever,  but  n, 
.spots  are  not  detected.       There  are  usually  some  symptoms  pointiu-  to  ih,. 
involvement  (d"  the  bronchi  or  the  lun,i:s.  ami  the  respirations  are  liiirri.~|,  onK- 
Jiowever.  in  proportion  to  the  fever,  and  the  phy.sical  signs  indicate  iml,,.,' i 
catarrh  of  the   larger  than  of  the  smaller  tul)cs';   there  is  no  iliilness     Tin  v 
are  headache,  delirium,  particularly  at  night,  and  .^^onietimes  mar,  .,|  ]m,„ 
arsthesia  of  the  skin.      .Vlbiiminiiria   is  often   present,  and  there  \m\  bc'cliin. 
plete  suppression  of  urine.     The  fever  varies  greatly  in  intensity,  hut  iisiinllvlih 
not  the  regidarity  of  typhoid,  and  the  daily  exacerbations  are  more  niarkci'l    It 
may  rise  to  104°  and  10.-)°  F.     On  the  otlier  hand,  there  are  cases  in  which  t|,» 
ievcr  is  moderate,  not  more  than  101°  or  10l'°.  and  very  rarely  there  nmv  Le 
no  tever.     There  are  also  instances  ir  nhidi  there  have  been  rigors  tliroucl,. 
out  the  course  of  the  disease.      The  condition  of  the  child  becoimrs  iiir-ravateil, 
and  with   a  dry  tongue,   delirium,   unconsciousne.ss,  distended  abdnin,.,,   ,.|,|,i 
swolleti  spleen,  the  similarity  to  typhoid  fever  is  very  close.     The  com-sc  is  m- 
trcmely  variable,  and  while  death  may  occur  at  the  end  of  the  second  or  hem- 
nmgof  the  third  week,  in  other  cases  the  disease  is  prohuiged  to  live  or"si.\ 
weeks.      In  the  more  protracted  cases  definite  local  sign-  are  met  with  ;  iIhk 
with  an  increase  in  the  dyspnoea  and  cough  bronchitis  of  the  .smaller  tiilios  i.i 
fi^und,  and  jiatches  of  con.solidation  at  the  ba'^^es,  so  that  aeration  is  very  (Ifftc. 
tive.^  The  eruption  of  tubercles  on   the  meninges  may  intensify  the  cerclml 
manifestations,  and  there  may  be  from  the  outset  .severe  headache, 'with  a  irrailid 
and  progressive  coma,  dilated  pupils,  and  sometimes  strabismus. 

Pit/iiioiuin/  Ti/i»:—Tho  clinical  features  are  (.f  an  intense  capilhirv  linm- 
clutis  (broncho-juieiimonia).  This,  the  more  nmimon  variety,  is  wn  oltm 
mistaken  at  its  onset,  and  even  throughout  the  course,  for  .siiii|iir  liiomlin. 
pneumonia.  The  onset  may  be  abrupt,  and  even  with  a  chill,  but.  a-  :>  rule,  flie 
child  has  been  failing  in  lic;ilth  or  is  at  the  time  convalcsciim  from  -,iiiie  iiciite 
illness  or  is  the  subject  of  an  acute  naso-pharyntreal  catarrh.  The  fcvir  is  Mnii, 
and  mjiy  reach  from  10:5°  to  10.',°:  the  pu'lse  is  rapid,  from  l-id  to  14ii, 
The  respiratory  symptoms  are  marked.  At  first  the  shortness  of  breath  is.slJL'lit 
and  pr,;p,)rlioiiate  to  tiic  fever,  but  gradually  it  increases,  and  the  rcspinitiniH 
may  l)c  from  00  to  70  per  minute.  The  cough  is  fre(|uent.  div.  and  v<rv 
troublesome.    As  the  dyspn(x>a  becomes  more  marked  thecolor  of  the  ih.rcliaiiL'i'^, 


and  flicreis  si  in 
diiM'c  iirc  rarel_ 
ilnra,  but   ti.e  ' 
/iMr       Tlie  will 
'ilivsn  al  exaniin 
I  till'  l<i\\er  zone  (j 
;iiiil  aiisciiltalion 
ilic  Miialler  tiili( 
I  iiiiii'li  (he  r(sona 
jinviiig  l)reatliii 
The  course  o 
hmv  die  at  the  e 
[ficative  catarrh- 
rum  !i  progressiv 
Diagnosis. — 
|wyi>r  beset  with 
iiPi  account ;   tin 
I  ifi'ii  instances  of 
IMiii'Ii  more  impo 
fiuicnt.      IiKpiiri 
I  Jiseasos  not  infrof 
ofliiiling  health  c 
o;i>('S  ai'c  those  in 
?"im'fiincs  the  aci 
tlio  iicck  or  the  of 
or,  in  very  rare  in 
lyjic,  when   the  fei 
flvi'i'  may  be  extrc 
record  he  kept,  it 
in  tnlicrciilosis,  an 
roiiiis.sions.      As  m 
fvensuhiiormal,  in 
MMic  in  both  disea.-^ 
|ii-ii;dly  present  in 
'He  sign.     Kxpecb 
fliniild  he  looked  fii 
miliiiry  tnherculosis 
'liiili  tiihcrcle  baci 
The  cxaminatio 
fntasfroipientlv  in 
jlmnM  he  carefully 
lavi'  resiihcd  fhuu  i 
The  profound  ii 
•liat  of  aciifi    tuben 
frtitni'os,  would    bo 
ftiiaiTlial  or  iironcho 
in?  "f  the  acute  tub 
Prognosis. — Th 
tMiicntioiieil  ii  type 
•"lii'i's,  which  tliev  ( 
te either  the  first  nia 
<"'  'lie  e.\-pressioii  of 
tuljcrciilous  process. 


iUO 

iiiiii  rlioro  is  , slight  (•yanosis     'ri„.ii,rl,  «i     c        •    !•  > 

aii.l  aiiscnltatioM  at  first  .sl,..,vs  .;  „       ,•':''    ""'"  !'^  ''''■••,"•■  •'^■'■"  l'y|...m.soM,u.t. 

i.Ui-..'  breatln,,.  n.ay  lie  lasml'    .•  ,   '    V  '  '      '"'"'•  ""''  '"  l''"^'*'^  '"■^''"••t 

.:.y.ii."at  tlK.  o,.,l  of  a  w..L "  ■  !  ,  \^  H  ,"";  I  -'-. -M'i-i.  -.1  -i:..  cIuM 
f.nt,v..  c-ata,Tl.-,„oro  .onnnonlv  in  on?  i,  t  '  L  7"^  "'  ''!'  "•'"*'  -''■ 
fm."  I.  |in.L:r,.ssiv,.lv  advancin-  asp|,v,i."  '^^^''^i'"''  '"'urtm.  davs.  nsnallv 

.'n:::::^;;];  tl;:;!s;::;':,;^^  '••''■-"•-  -.,  i.. ...... 

".-.ronnt;  tin-  s„,-na.n.lin;,s  <  f  ';:  J  "  "S'  '^''7  t''"'"'  '- •^''-■" 
i.'n  i-.stancos  of  tnlxTCMlosis  in  tl.jL'.'o-^' '''"'''"''  "'^•'•^'  '"'v.' 

P'iont.      In, -i.-s    sl.onl.l    l.f  ,'  ^  ^.T"'  '"'""""'  ;•"'"""""  "''  'I'o 


ili-ensosnot  infrequently  f<,llowe,l  l.y  „.;,  i  "'"'."I''.''^'-''""^'!'  .-..,(1  measles, 
of  fiiilin.'  Iicaltl,  ,!r  of  protraet  e a  .n  .  '"'''■"■"  "•"V^-  ^^'»"<-tinu.s  a  historJ 
--  -■-  .1.0SO  in  whiel!  the,"  1  ^  '/£,'?, "^'fr"'"     ,''''"•  ■""'^'  --'-^ 

Soniotinavs  the  acute  urteetion  f.-Ilow^'n,:;;^  .''''■  "';  '"'""  tnhereulosi.s. 
tLoneek  or  the  opening,  of  a  joint  ,1  .  '  ''.  '"\  '"  '"'''■'■'•"'""^  ^'lan.ls  of 
«'•.  i>i  very  rare  in  .tani^s    ,1,/     li  m     f  <'^<:" ,'>»  'i  •'^o-calle,!  ool.l  al.seess 

-vp-.  wlu^.   the  feature;    re  i.    TS"  1,1  ';;""'"'  r"'"'""'      ^"  "^  ^^1'''-' 
f->nnay  he  e.xtren.olv  close.         e         '  f  L  '     ^""••'"^'""  "f  "'•••inary  -e/Heric 
rKora  he  kept,  it  uiirn:...umy  bo  f     n.    ,h       h    l"  '  '"  '"'f'''^  f^'"'l>.M-ature 

■"  'Hl^reulosis,  an.l  ea.ly  in^ho  .li  t  h  ,  ';  *"  l' "  T^'  T\  ^••'•"^"'- 
roinissmns.  As  noted  l.efore,  in  a  f.'W  inst' m les  'l  ?  '""'  """■'^*'''  """"i"g 
wn  suhnormal,  in  the  niornin.'  The  ...  i.  .  V  .  '  ^^I'^^.' -'tare  may  ho  low^ 
.'»'ii''  in  hoth  .Iis(>ases.  Th,>  ahsen,..  of,  '  T  T'  "  '"*^'^'ti"n  are  inucl,  the 
h-lly  i---nt  in  ohihlren,  ;::'";. ^;^::;i';:r'':  ""'-^  ^^  -  there,  .hi..!,  is 
tivcsiirn.     Kxpeetoration  is  rarolv  oh"  •■    1  .  "'  ,",  ".'"'^  ""l-oi-tant  ne-u- 

»"li^'>'y'"herenlosis  takes  its  o     /i     in     ^m  iP  ''r,''''''P"''^  ^''"^  *»"  ^''-'••te 

"":,!:  "'•-•'••^'  ''-il!i  "-.y  reach  tl.'p^t,:;;."       "'  •'  ^^'"■"'^ '"  «"^  '""g'  f'-n 

- '''h;;^:':;:;;.';:;;;!;;;^;'''^^     y  Ehrnch-s  reaction  is ,.,.. 

^"7-''""'  fVonl  uro^enual  tuhe'S^  '''''''''''  of  general  infection 

;'7-vo,,hl   he   in.portant    di^t^^;!,  ^^j   i;';;:   "*  l^-*'  --1  -'''olic 
'"'"■'•''"'  '"•  '"•oncho-pnennmnie  tv„<. .;!  7        I  u       ' '"',  <''".2iosis  of  the 

•l-».  .I,„.|,  ,|;,'v  ,.  I      '  ,,'"      )"  '■'■'•"!■""»> v  Kn.I.i».  I„„„l,,„v    "Z 


/    K 


1  T 


KMi 


.i.i//;A'/r.i.v  T/:.\r-/i()()h'  or  ihseases  oy  ciiiijhu:.^ 


the  tciiiiK'niturt-  ciirvi'  would  iiut  ii|>|.ciir  to  ;.'ivf  imv  di'liiiitf  nitcrion,     !  ij,,,, 
ill  Ihct.  tlicrc  is  suiiic  iociil  iiilpiTcnlniis  focus.  |  do  iiot  sec  Imw  tliix  fonn 
nro^nizrd.  Mini  niaiiv  oftiii'  cases  reported  l.y  A\  irii;,Miet  in  liis  iiioiioirn,, 
not  at   all   eoiniiiciii;,'.      'I'liat    there  may  be,"  liouever,  either  earlv  in  :, 
oiilosis.  or  as  a  secondary  event   in  a  loe'iil   process,  an    int'ection  of  the 
tlie  toxines   is  exlreiiiely   iikelv        in   adults  it   is  not  verv  uiic( 


Wit 


'■|lMr;|.', 

liU'civiir 

If  :ici|tr 
/■'■  tVoili 

oiir  or  liv,.. 


II  arc 
I II  her. 
,'lci,, 

find  II  tuheiruloUM  focus  completely  overlooked  in  a  ^.'eiieral  infection  iMlievwl 
to  he  typhoid  fever,  and  in  wiiich  the  secondary  development  of  niiliar\  .fctnu. 
lations  soom.s  scarcely  sullicieiit  to  cccount  for  all  the  svmploiiis.  '  * 

(2)  Cmiionic   Diiiisi:  'i'l  iikkci  i.i.sis. 

This,  one  of  the  most  common  iiirms  of  tuherciilosis  in  children,  i- 
terized  anatomically  hy  the  ;.ri'adiiiil  development  of  tuiiercles  in  niiiia  > 
parts  of  the  hody  :  they  are  not.  however,  tiie  miliary  ^.nanulations  o|'  i 
tuherciilosis,  hut  coarse,  grayish-yellow  tuiiereulous  niasses,  varviii"  in  - 

ii  pen  toil  walnut.     In  the  liiiiirs.  for  iii>iance.  there  are  cas is  tuiieri'lc 

.sizes,  areas   of  (nisoous   hroiicho-pneiimonia.   some  of   which    have   uin' 

."ofteiiini:;   hiit  cavities  are  not  common  except  in  children  ahove  " 

The  hr-uichial  ;,dands  are  often   ijivjitly  enhirjred  and  I'aseous,  ami  xuiiciniiis 

present  ahscosses.      The  ahdomimil  or^Jins  show  extensive  tuherciilovi,.     'I'l,,. 

.spleen   is  ^'reatly  eiil.irjred.   and  on  section   presents  numerous  ;,'ravi>l.-\(HMiv 

tiiliei'culoiis  masses,  varying'   in  size  from  'l  to  Id  mm.      'i'he  liver  is  cii'lar'cil 

and  may  show  miliary  tiihercles  on  the  capsule,  hut   in   many  iiistaiicis  tli'ri- 

!ire  coarser  yellowish-^rray  masses  which   have  developed    ahoiit  the  l)ilc-c'a|iil- 

laries.  and  whii'h,  iuiviii;,'  s(d'teno(|  in  the  centre,  present  a  yellowisii-L'iccn  hji,,. 

stiiiiied  pus.     'I'lie  small  intestines  may  show  tuherciiloii.s  ulceration  to  .■!  ;.nv,iiir 

or  less  extent.       The   mesenteric  jrliinds   tire   usually   enlar^ri'd   ami   •  ;im;.iii,. 

Tlie  kidneys  may  show  coiirse  tuiiercles,  sometimes  an  intense  tuherciiJiMis  ini.. 

litis.     In  the  hrain   there  may  he  either  an  acute  tormina  I  menin^ritis  m  i|,i  , 

are  coarse  tuberculous  nculides  scattered  throughout  the  siil. stance,  piniicni, 

in  the  cerebellum.      The  chronic  diHuse  tuberculosis  is  muv  h  more  fivi|iiiiii  li, 

infants  than  in  children  above  i\w  a,u;o  of  two.      The  symptoms  are  lli  -,•  uf  ii 

proixressive  enfceldement  of  the  nutrition,  as  a  rule  iritlioKt   f,-rn:     ml  witb 

inanifestiitions  in  different  orf.'ans  varyinjj;  with   the  de-zrec  of 'tubeirilizatinii. 

'i'he  affection   may  set  in  iiciitely  as  a  bronchitis  or  a  broncho-pncimiipiiia.  tlie 

symptoms  of  which  <rradually  subside.    Very  often  the  condition  follows  ivlmnii- 

in<j;-cou;,di,   measles,  or  acute  <];astro-intPstiiial   ciitnrrli.      Less  fre(pieiitlv  it  is 

insidious,   and  the  child   presents  simply  pro._rressive  failure  in   hcalili.'   The 

a]»pc!irfinceof  the  child  is  that  (d' marked  cachexia.     It  is  thin;  the  skin  i*  I ei 

and  pale,  .sometimes  covered  with  line  scales,  and  occasionally  pi^mciiiiMl.    Tiioi 
eyes  tire  lar,ire.  and  the  expression  often  brii;ht  and  animated.     Tlir  tlmrax  ij; 
thin,  the  ribs  readily  noted,  and  there  may  or  may  not  be  the  siirns  of  rwshi 
ill",'  rickets.      The  abdomen   i>  usually  tumefied,  and  both  the  liver  Mini  ^plfcn, 
are  enlarjred.      When  the  abdoiiunal   features  are  marked,  the  cliincMl  jiit'tiire 
is   that   really  of  some   cases   formerly   described   as   tabes    nicsenriiii'a.    Tlie 
.superficial  trlands  may  be  enlar^'ed  and  li;ird.      ( 'ou,t;h  may  be  pre-cnt.  iisimlh' 
dry,  and   very  rarely  there  is  dyspiia'a.      The  physical  signs  ilioi(,ii;,'li()iit  llioj 
liinjrs  are  either  dulne.ss  in  the  interscapular  rejiionsor  scattered  ;iiv  isof  ilctlc- 
tive  re.sonaiice  with   bronchial    ru!"s  and   blowin;^  breathing,'.     Tl;     ijijietiti' lil 
Jioor.  the  di^restioii  feeble,  voniitinjf  is  fie<|ueiit,  and  diarrlia'a  is  c    iinoii.    X"t| 
only  may  there  be  no  i'rwr,  but   the  temperature  may  even  iljiioniia 

Death  usually  results  from  some  compilation,  either  a  secondu       evasion  o 
pneumococci  or  streptucocci,  or  an  acute  meningitis. 


I")  I  riiivitf't, 

•r;ii  of  tlie  disea 

i<t'i'iiiis  surfaces). 

if  ll:c  viscera  or 

!"liiri'  supposed. 

rliililrcn  there  m 

iMilitful  cases  Ilia 

iiA  1'u.scal  have 

iiiviilvi'iiient  of  til 

llin'i'of  tlic  a  \illi 

ilieiiflk'tioii  III  SOI 

llicv  hclicve  the  d 

leniiizeil  eiilMri.'eni{ 

'iilioiit  iiiiicli  feve 

"if-'aiis.  and  fr 

The  c'iscs  must 

'Wit  of  tlir  lyiiip] 
feisf  ill  cliildi-en 
t  involvement  of 
tf>ii|i|)(i>r(l.  howev 
;"|wficial  lymph-^r 
'"L'kin's  disease. 

'(■iiiiiTJi  of  the  iipp 

l"i!'H:irt'Miciit  of  the 
'■"inlition  of  the 
''I'fiVycr's  folli, 

!''''il'l'™  lii'Md  of  om 

illlll^S, 

'''I  I'ljiivicu,  Ai 
""■'"■t'k  (.'111 brace  tl 


iterion.     ! 
this  fDriii 

<    lrlU||t(J.'l;i 

•iiilv  in  , 

II  I'f   tllr 
V    IIIU'llll.,, 

foctioii 
>t'  iiiiliiii 


!i  ;iiv 

.-tfiil 

'Hi,      t,, 

.'raiiti. 


llll'CII.     i>    clllll;,,.. 

II  iiiaiivilitrciviir 

UllS     ..!'    lil,.    ;|,.||J|. 

'iii^'in  -I/.,.  (V„||| 

tlllifrrlr>  ,it'a]| 
iiivc    iiiMlcr^'Miie 

•M'    liilll-  III-  fivi.., 

iiiid  ."^diiictiiiics 
(•i'ciil(i«i>.     'I'll,. 

j,'riivi>|,.vi.ll„iv 

ivt'l'   is  cliliii'^H.il 

iiistjiiiivs  tlicrt 
t  till'  lnic-ca|ii|. 
visii-jrrci'ii  liil|..i 
ion  to  a  ^'iviitir 

1    Mini    Ciisijniij, j 
iljci'fuloiis  jive- 
inj.'iti.s  (ir  tlil'rei 
L't".  |)iirti('iilai; 
JI'C  tV('i|l|rIi|  in 
are  tii">(.'ut'a 
'''vrvi\     ml  with  I 
iilifi't  ■liizatiiiii. 
iiH'iitiioiiia.  tliej 

follows  wilnnp. 

Vt'(|iii'iitlv  it  \A 
licahli.'  Tiief 
u' skill  i.s  iiiii-ei 
^iiicntfd.  Tiie) 
'I'lic  thorax  ii| 

^IIS  (it'   CUfXist- 

V(T  and  spliriij 
liiiiral  jiictiirtfj 
■iiifi'ica.  Tliol 
'•(•~r!it.  u?iiall_ 
■"  '^,dioiit  tliej 
..ilMi.f.r- 
lii    ippetitf  M 


iiiiciii.  Ni 
il»ii(inii;i 
ivasiuii  u 


'rriii:iicn,usis. 

MnMitution.:  ami,  sn-ondlv.  .'..•    i      |      '     ■"'T"  '"    "'"'"^.  l-Vtinilai  y 

:i::M.i.  'd  til..  int..,s,i,u.,s.    Tj.i.s  ca ...  I,    .     "";'"";j''s  iiou  „r  ,i„,  |„„„,    ; 

I""-'-";  ••"-;  iH-.iis.ii.,„isi...d  iv:,:;\  ::''■■';!''• '''"•'-  ...i....vni;;i;: : 

.:iianli.  and  of  ,MV|diilis.      I,,  n..L..f-    i     '."''^"•^>  "'  t'lii'onic  -'astrn-i,,t..stiM..I 

.ipunant  ii..^.a.iv,.  si,.,..      \  ,r,,,    , .   i:'/     ,"'''"  I"'  "'  ''"'  lvM,,d,-;,la„ds  is      , 
.i.cas,s  "'•|.ndou,.ds,,.I,ilit':'  ,^  '"  :^7  "-'f  in  .lis.n,,Llu,..    ..,  ^  1  ' 

r".''K-'i  juid  ,i.,..,d....i.'and  live   .::;,:,;;:,  '';-"i-'i-''i ^i.n..i; ,...v  ,'. 


in.  LocLAizED  Tuberculosis. 
(1)  Ti-,i,,,„ri,os,s  UK  Tin;  I.VMn,-.,.,^,.^ 

<f"t  ''f  tlH.  disease,  and  rli..  .li.nds.'  ' u.uZ^'^^^'^Z  '''T'  '"7  ''"  ^''^'  '•'''-'' 
,">'i'mss,n(a.rs),  in.'iv  present  adv.n<-..dt,.  ''"'.  '  •^'•■'•""'-  "      lie  lv..,,,l,.sac.s 

V'"'  —  -•  otliVi'  pa..ts.     'n;r^r;,^  ;:';;-;,' ; '.  in volJ-ement 

t  ' e  s„,,,,ose,l.  In  .son.e  instances  of  -^ener-  ,  I  ,  l'  ''''"'  ''■''  '"'^•^'  ''*■'•■- 
''M-l'vii  there  n.ay   he  what    l.e.r,.o„v  :,•'"'"'"'"'"  ""^''''i""  in  v,„u..r 

a>i'i  IWal  have  deserihed  .as,.s  j,.  ehihi;  .  i     )     '■'"  '"''"^'"^'^  J'^'^"^'^' 

r'*'^'""'"^  "^  ""'  '.vn,|d,ati,-  ^dands        ,  i  V       «     ' '',  '''''''*'  ^^••'•^  l"-"^"vssire 

"-f  tl-  axilla,  and  lastly  tl.e  cenS'S'  n    !'"""  "''  '''"  ^'•"'"-  "'<"' 

■:a  oction  ,„  so„,e  of  the  Jases  as   I  o    ,  n  :"'"'  ^7""!-;      They  re-rard 

,J";Mu.vet).ediseas,.toheeon.n.|.    ;      ^'y,  ""-'-"•^  tuhere.dosis;   i„  ..tluTs 

^n.ml  eMl,-.r.en,ent  of  the  sn,.,.W  .![   ;,,,''"  r^''"''''''"'^  "»  ^'''-^  '•'"••n  of.,,,. 

'«"" ■''  'i'vei-and  withou!     ,  ^     \         ^'i;;!' ^  "T  i'-^'-ivoeaehexia 

,.i  ::•-;:  i:;;;ii^;;.:d:i;;'t;:i'^-^:;;:^t  '■-\  ••-  ^<-'"  ^h...  e,.,ai,.. 

-e  in  eliildren,  in  wlii.-h.  h  .  I  "I  ^Z-         '"''■  '""'"'  "'"  ^'"''^'<in's 

t^<"Ppos,.d.  howeve,-.  that  eJerv  ^^oriTl"  ''T  """'^•■''-      ^^  '""^t  no 

;;i;'-''  ^-i'i'-;:i-,ds in ehiid,    •: ,r     '";'*Yr'' "t''r^^       "'<^ 

""'iL'in  s  disease.    F.diouin,.  tl...  info,ri     '  i.v  '    "''•''•^■"'"■^'■^-  ^vpliilis.  or 

Jf'l'  -f  tlu-  npp..r   ai.-pa;;a...s  :^    en;""'  """T"^*'  "'"'  '•'"•""'- 

«A":^;:inw,t  of  the.   -dands  of  the  „  ...k     ,  f   tT  •""""'  /'"'"   ""^'  "^•••"•^'-" 

''i  Ci:i!vic,\/,  Adfntti*      'im,     i    • 


:  I 


in 


1U8    AMKIilCA.y  TEXT-BOOK  OF  DISEASES  OF  vniLDRK.\ 

The  most  important  groups  are  the  superficial  cervical,  bcnciith  the  plrvsm 
which  (Iraiii.s  tlie  side  of  the  liead  and  neck  and  face  and  external  ear    ,,1,1  fl 
deep  cervical  along  the  carotid  sheath,  which  drains  the  mouth,  tho  •n,i<il'" 
palate,  pharynx,  and  larvnx.      In  addition  there  are  the  suhniaxill  ,i\  V'i 
suprahyoid  groups  drainitig  the  lower  gums,  the  front  of  the  mouth  and  ;,,„', 
anil  the  chin  and  lower  lips.  "    ' 

_      Tuberculous  adenitis  of  the  glands  of  the  neck,  .so  extremely  coniinoi,  ui,;,,), 
tortunately  often   reiuains  a  local  and  curable  aflleetion,  was'reganlcj  ;k  ,i,  . 
of  the  most  typical  and  characteristic  manifestations  of  scrofula.     Cornel,  o'k,''^ 
rations  ujioii  the  presence  of  tuliercle  bacilli  in  the  dust  of  cities  and  ,,r  ^Z^Y 
shows  how  widely  spread  the  virus  is,  and  how  liable  we  are  in  crowd,  J  ,.'itj!i' 


ler  the  1,,|,.|| 


Mrilli 


'»}'  I'xtR'uiel 


to  inhale,   and  even  to  swallow,  bacilli   with  the  dust.      Whetl 
are  capable  of  passing  throngli  the  healthy  mucous  membrane  is  perhaps  .|oi|!,t 
fub  tliough  there  arc  experiments  which  "would  seem  to  prove  the  lialiilitv ',r 
infection  through  the  healthy  nnicous  membrane  of  the  intestines.     M,,iv  iiVol, 
ably  the  slight  catarrhal  troubles  about  the  naso-pharvnx,  so  fre(|uciit  ii,  ,.||'ii" 
dren.  ojx-n.  as  one  may  say,  the  portals  and  allow  the  bacilli  to  reach  tli,"  Ivinni, 
glands.     Preliminary  irritation  and  enlargement  of  the  glands  in  eczeiii;M,rtlp 
scalp  and   in  sore  throat  in  children  mav  weaken  the  powers  of   rc^isfu,,.' 
Here,  no  doubt,  if  the  tissue-soil  be  unfa'voral)le,  thev  mav  exert  no  \\x\Wm 
whatever,  but  with  that  vulnei'al)ility  of  tissue,  regarlled  by  f.ruier  urinMN.,s 
the  characteristic  feature  of  scrofula,  the  bacilli  find  a  suitalde  nidu 
local  tuberculosis  is  the  result— a  process  characterized  usiially 
chronicity. 

The  glands  may  enlarge  ra];idly  at  first  and  become  .soft  and  painbd-  mom 
commonly,  they  swell  slowly,  and  can  be  felt  as  firm  rounded  iii,K.,s'r,v, 
movable  beneath  the  skin.     They  may  gradually  subside  and  under-,,  .,,„„ 
taneous  healing.     In  other  instances  the  glands  increase,  iireas  of  sort,i,ii,,'.„ 
found,  the  process  involves  the  skin  overlying  the  gland,  which  bc.'onicMv,! 
and  finally  ulcerates,  discharging  a  cheesy  matter  and  a  thin  wat.'rv  ^To-mii 
ihe  .sore  thus  left  is  very  indolent,  does  not  tend  to  heal;   the  skin"ahoiit  it! 
livid  and  undermined.      Many  of  the  glands  may  .suppurate  in  this  w,v  ■„ 
when  healing  ultimately  takes  place  the  sides  of  the  neck  are  di^li-mVil'l 
irregular,  unsightly  scars.     In   the  neck  of  young  or  old  these  are  u^uallv 
certain  sign  of  healed  tuberculosis.  '  ' 

It  is  to  be  borne  in  mind  that  involvement  of  the  cervical  ^A-m\A<  inn  ' 
due  to  extension  of  tiibercuhms  processes  from  the  axillary  -dan,^  orcvcn  ilnii 
carious -cervical  vertebne.  When  the  glands  are  large  and  <rrowi,|,.  activt 
there  is  fever;  death  very  rarely  follows,  ami  even  ag^'rava ted  cases  in  chiMro 
may  recover.  In  some  instances  the  genera!  nutrition'  is  verv  sli^diflv  distinlir, 
riiberciilous  adenitis  of  the  cervical  or  axillary  groups  may  prm-lr  ih,.  ikvo 
opmeiit  of  tuberculosis  of  the  pleura  or  of  the  lun<' 

(<•)  Tkaciiko-iuioxohial  .u.anos.— Within  the  thorax  the  -rnMpsoflvmi.l 
glands  arc  of  great  importance.     The  sternal  are  placed  along  the  .-Miirse'df 
internal  mammary  vessels;  the  intercostal  along  the  heads  of  the  rik  iiiij 
sometimes  extending  outward:    the  anterior   mediastinal    group   iHtwmi  tlk 
lower  part  of  the  stermim  and  the  pericardium;   the  cardiacV"!'!'  "i  tlic  iiitJ 
pleural  spaceabout  the  arch  of  the  aorta;   and.  lastly,  the  tracli'cil  irlaml^ 
either  side  of  the  windpipe,  and  the  bronchial   propl-r,  continimiN  uitli  tM 
which  surround  the  main  bronchi  and  ])ass  deeply  in  the  hilii^  nf  rlic 
There  are  al-^o  glands  in  the  jiosicrior  mediastinuni  along  llif  innnicic  ,ini| 
and  oesophagus.     Tuberculosis  of  the  tracheo-broncliial  glands  is  cxtiviiiof 


foramon.     01 

[  jliinds   bacilli 

very  l.irge  \)\\ 

tliiit  tile  first  ii 

oiiitrary  to  tin 

invdiwd  witho 

.Viiiiiriip,  the 

Diusscs  in  the  1 

ami  elsewhere; 

Bwv  1 1  resent  gi 

iif.soficuing  wi 

cast's  I  here  is  ni 

vdT  ilifferentlv 

I'lvaf  iiivolvem'c 

:;iiiii!s  are  invol 

;ii;_'i' caseous  nia, 

Jii'l  jii'iK'tratiiKr  , 

Ml 'ill'  'he  absces 

Ifliliir^'cfl  glands  ji 

fi;i!ior;i!c  section 

faciit  licre  to  sa 

iiipcridr  c;i  \-a,  „f 

!iii'i  iiroiiclii,   thoi 

wit'iiiiiogastric  nei 

/laiifli.      .Aff)|-e  i, 

"tii'iicd  glands  im 

'iiiird  Ijciween  tli( 

loM'ls  lire  much  le; 

fciiioii  of  the  (jes(. 

ii">t  serious  effect.' 

jaiiiated  deej)  alonn 

ledv  direct  contac't 

\k  caseous  bronchi 

kIiit  instances  it  t, 

[iui'inir  rarer  seipicii 
[in;  adlicsioii  ,)f  ,,„  ^ 

k'lf  the  anterior 

Hwiiloiis  adenopa 

NiHicd  ;r|a,id  into 

Symptoms. — J„ 

I'i^aicvcr.  and  even  it 

H'f-     Aufho,-,s  di; 

pi  J  think  correctly 

Wm^A  Ihe  vei„.s" 

iS"'iiiidha'iii„rrlia(res 
'•ifimctcr  of  M,".  ),, 

l'"'"^'i  f'.v  "ie  same  w 
.*;  'iVipiendy  in  til 

l*''"'"»^'>  '■vaiiosis,  ar 

'«'  piii'o.vysms  may 

"'•Ii  to  iiivssiire  at  tli( 

,    "'  fiiis  Way  lar' 

fres^ion  of  one  or  othei 


common.     Obsorvation 


'lands  biiciJl 


1  may  |,(.  p,.^, 


'f  I^ooinis  (J,..)  ,sl, 


wy  .trgo  j)i;o;,ortion  of  ulj 


at  tJif  Hivst  itifoetioii 


ow  even  that 


fiiiid'a 
I  iir.iih'.'ii 


>\  to  tlie  ,>so.calle(l'l 
wJtJiont  any  local   1 


wa.s  in  tlicso  st 


aw  f; 


I'iniiii 


I  masses  j 


""P.  t'lo  bi'onciiial  l\ 


^;^IOIl    in    tlio   1 


=';?Srrrfc«* 


'Pparently  normal 

in  a 

"ppear 


■^'"  it  woiibi 


"  >'■»  i'-s;;;ii' K;:  !.-i!.'* 


''"^'«-    Of  i2r> 


and.s 


lows. 


*  (-"i.sos  e\a 


"lily  be 


iiiinod  b 


"""'■'^'■'^"*^'-^;  i"l^.itwas   in.   , 

m;H'    ll|■('S(■ll^     ,„ -I-  ""IIUMI 


^"T''-.i«».;*™sr^,r?.;«:£.;::;;.;i^j 


;'}■  I'lvscnt  ^niy  ijjjjj. 


lorsiit'tiiiiii^r  witl 
iiisfs  thoro  is  niueli  sd 


■"•y  tiiberclys,   1 


t'J  tlio  bronciiial  .r] 


'  ^"PPnration,  ,„.  old  (l,, 


\  |'m>nt  tnborel 
'kIn  alon- 


P«  ill  flic  Inn 


">'';.   '"'pigiiicntcMi 


llflT    ill 


irterenflv 


^■'•"•^".s  and  j.i^rn, 


'"^•".Ivod;    thus  tl 


<-ififd 
('Illation 


nia; 


<:ni.\ 


f't  ".volvon,.ntoftbo'bn,nc-l 


'k>  di 


111  W 


'«y 

glands 
■^'■«».s,    f„ei 


Tl 


'10 


'0  ''>ii;,'-stan(l 


inir 


li'uini 


■"•('  'Mvolvod,  and 


^-■''-'".ay'b;  ;;;r^.r"j-'-yb' 


^■^•■•■ascoiis  masses  unifonnl 
B-llM'iK'trating  deeply  I 


r  /!'"'^^  ,p'-p-^  M 


vt-ry  often   those  d 


'\;">'^-''  aflected  witi! 


y  ■■^iiiTonnd 


i;  ;:':,!" ''-'"!■- "r.wi 


".'•f  <'oininonly  all   tl 


lioiit 


10 


Jjiiivilf  I  lie  abscosso 

Ifiilarircd  ii. 


I  - """"llir  tlie  iiimIi,  I  1  •^"i-  111 

"■""'■■"  liif  iok..,7,  ,1.      '"■"",':'"'»  ••""1  it»  <i 


:i;:rr";Y,i:!:';«r"--iS: 


^     'llO  lllll(r.         \\| 


Iriii'iunite  section   in  thV  '1 
Ifric'iit  1,01-e  to  say  that  tli 
'li'.Nar.l.,B'T'™'"*-'^''''  "f  thepnl 


--•2;vanod.andfo,.;;,i; 


yi'ciil  direeti 


<>ns. 


'.r."  f^"'  ^''aiid 


i  visions, 


laite  of  JJ;,,.,] 


'ii'lails  the  read 


'lo  e/1 


oets  of  tl 


>*  8np. 


lioi'e  ai 


Ijh!.  Iii'oiicli 


nioi 


■(•  mstai 


Ifta'iiinogastric  nerve  mav   I, 


'/■"•y  artery,  aiid  of 


'(•/  •i.uJ   ^  '"\'^"'<'L'i' IS  referr 
,  ,1;  '"'  ^^'"""*''  (tome  :j).     _[ 

'l<  OS   on    iv.„ 1      ,.  )•      A 


loferi'ed  to  tl 


lese 


10 


''"  J'f't^ord  of  c( 


it(eiie( 


tl 


""  ")•     -It  IS  snf- 
>iiipression  of  the 

fill  '-' 


biH'h.      M 


iciii'd 
Ifiniicil  I 


"'•£'  iiii})ortant. 


''t'   involved 


^'•^'  i-arely  serio,;;i 


'- -y.os  vein:     The  t^^, 


'••""'-^  '"to  the  bi^onel 


I'y- 


partieiilarlv  tl, 


V  ( 


impressed. 


"<-'   I'oeiirrent  1 


lea 
'ho 


|Vf\>t' 


•::^'^^^.^^^£S^^-^^-^^ 


siii-emuch  less 


i"y"gcal 
and 


Ifcition  oi"  tli 


(■'•mmon,  but  tl 


Itiiist  sc 
"iiiiatf 


'--opi.a:;;:;:;;';,rs'"!-..yart^;h;;,, 


^'HMl  bronchial  .Wand      l>    7  '^:''  '"^  ^^ 
-  Piilinonarv  art^.,-    .:,  /  '''''"'-^lons  of  the 


''"•lis  effect 


ci'n  dosei'ibed" 


iMiiis  enecr«   iu   ;..»■    ^'        —   ■"^•-■ii 


111  .sever  il  c, 


l>oen  opened.     1 


'er- 


11,.  '     -n  '"e  o 

fl)V(hrect  contact,  and  i 


"•'•"^•i'i.    The  i '.f  ^•"'  ^''"'"'^  ''y  tl 


iile  cast'ii 


'"■^  bi-onchial  ,rlan,| 


f  '"toction  m 


'«*?»•     Ono  of  th 


!""y  'h;  ditfieult  to  d 


lotern 


ly,  as  i 


'f  '''■'*.'«"«  glands 


IS  often  clearl 


liuii 


'^''  "-'ances  it  takc:s  j.Iaee    ,1 
'"'"^raivrseipience 


^--i'.atos  and  tile  n;;;;;:i".-"--ti<-\^^ 


soon, 


piiliiionar 


III:'  adi 


•"^'.  t'lo  root  of  the  I 


y  tissue  I 


iiore 


'ogins.     J 


-::^c"^^£i^-:-^^^^ 


"'ividuiis  a( 


and  aortic 


'■"**<|"ont  retract 


'sop, 


''''g'i«  follow- 


""•  and,  in  the 


.'I'llCll 


L'Imik 


Symptoms, 
I'iMifvci'.  and  even 


"'<'nopathv  •in.l  .      •       ,       '^'  /''"O'llis,  the  ^\•iu,^,     \  ''  '"  the 


II   tlu 


K-irdiiim 
g''cat   iiiajority  of 


"'■  I'y  niptiiro  of 


iFwit.    Aiifl 


|ii-iltliii)k 


'I'lrs  diff; 


1"  cnorinons  enj 


••  f'.xti 


iFi'-Hi'ii  of  ill 


''•"■'■<'<•'' ly.  'Iiat  tl 


'*'"'<''y  in  th( 
i<^'  iiianifestat 


'."■g<'iiiont  press 


instances  tl. 


ii"  view.v 


■llKvinorr       "'!'''"^^'"''''>I-v,d 


Ions, 


IM-e-sio;n.s  I 

on  tl 


^''■«'  arc  no  indicati 
'.'■■'y"ot  havob 


ions 
con 


as  a  rule. 


?-^'-n.er,:fi;;;,;r;:!t  ;:.s^''-''fti.e. 


;;  P-""t.      Many  hold 
■>'<■  vorysli.rht.    ( 


I'actcr  of  the  1 


('.V  till 

'Urv  ih'(|iii 


lieai'(. 


■soiim 


aiiie  writers.      Th(.  I 


f  and  attacks  of 


'<'z  and  Sjini 


<'iiis  cauf 
Al 


\\\\i 


'IOC, 


oin- 


lO- 


Irratli 


'l'"""y  ill  the  aft, 


itfer 


paro.vysnia!  i|v, 


cyan 
'•'I'ations  ii 


r"""^'  <'ya"o.is,  and  coh 
I      paroxysms  n.,y  succeed 


pdi  to 


'';"""",  and  (hei 
''"(•at.s,  almost  lil 


*'"/'  "n  suddenl 
110  o|)j 


'c  I'S  oxtren 


ft 


piKOa  are  d 
<'"  at  re.ruli 


'''■fr'"'^'  at  the  bif, 


each  0(1 


Y  ■■'"  attack  of 


'I'cssion  with 


les- 

itr 

apid 


.  ■•"    '-^  lllO   iHtlircatinr,  of  fl,     , 

-'-'''-^;:^,/;:^.v^cai,..n.^1;o;;:'t:;:-«-.P-.^^ 


r''onofoneor^.S'? 


'  '11)0(1  not 


.so 


'■oiichus, 


''  ^'au.sing  feeble  b 


♦""'  '     '  .  '.*'  'si  I  no  com- 

'""  "»  the  side  most 


'i-eath 


i 


I   :  I 


110    AMERICAN  TEXT-liOOK  OF  DISEASES  OF  CHILI) HE... 

affoctod  witl.  sil)ilaiit  and  fine  nllos.      Usiiullv,  liowover,  wlioii  the  -],,  ,|, 
very  iiuidi  ..nlaiigfd  the  lung  is  also  involvc-d.  and  it  niav  iKMlilficult  t.^  ,\   ' 
tar  the  alterations  are  due  to  the  clianges  in  it.      Still  hVss  reliable  is  tli.  i„| 
niation  obtained  on  perenssion.  for  tl.e  dulness  in  the  iipner  j)art  of  the  m. .,■„,',"' 
and  in  the  interseapnlar  spaces  is.  when   present,  hv  no  means  a  posiiiw.s|,'" 
I  lie  thvniiis  may  eaiise  .sternal  flatness  on  percu.ssion ;  and  behind   nnl,«ri" 
glands  are  enormously  enlarged  and  the  ehild  very  thin,  it  is  difheiilt  t..  ,|,.|  " 
mine  any  special    modification   of   the  resonance"'  in  the  interscaDiiim    s,,.!'' 
between  the  first  and  third  dorsal   vertebrte.  '    '' 


(r/)  Mks|.;\tkrio  Gl.\M).s  (T.ahes  Mk.'^enterica).— The  glaiid< 
mesentery  and    the  gastro-hepatic  omentiiiiraii<l   ti 


are   those  of  the 

of  retroperitoneal  glands  along   the  aorta;    moVe  rarelv   tiillseilt 

iiiljerculous  disease  of  tlie.se  glands  is  e.vtremelv 

of  fatal  tuberculosis  in  ehild 


iiiviijv,,! 
i-liiiiii 


common  ;  thus  of  Ij 


volved  in  100,  while  Ashbv  states  that\)f  10 


ren.  noted  by  Woodliead,  these  strtictu 


res  uci'i 


Ill- 


children   dying  of  tuliercuh'isi.s.  in  t)2  there  was  tuberculou.s  uleerat 


intestines  ;   in   7 


1,  el 


eesy  mesenteric  c;lands  ;   in 


lami 


both  ulcei'f 


iiih 


K 


m  7.  tuberculous  ulcers  without  involvement  of  the  (rland 


>,  cheesy  glands  witiioiit   ulcers.      Of  144  childrei 


:>  con.secutive  post-moiicms  „ 


"I   tlic 

^lllll  ill 


ainl 


rjand 


were  tuberculous,  onlv  44  showed  neither  ul 


■en  III  wliK 


h  tl 


le  Uh 


the  intestines  (iJarlhez  and  Saniiee). 


(•('rations  nor  tiibcric 


M'litcric 


n  a  great  many  instances  the  condition  is  found  accident 


who  liMve  died  o 


f   oti 


fig 


ler  diseases. 


11  res, 


tl 


I 


llllV   111 


ihili|ivi|| 


le  intcctioii  111  iiiair-  o 


of  the  intest 
1 


f  tl 


iKjiiestioiiabiy.  as  is  indicatcl   l,v  tii. 


iiie 


IS   ,iot   nece 


lese  cases  is  primary  in  the  ghi'id- 
iry.      Some  e.\periiiK>nts  have  shown 


-I'Slnll 


)acilli  may  gain  entrance  tlirough  a  healtliv  mucosa, 
to  the  ]iossibility  id'  infectiiui  by  the  baeill'i  in  milk 
we" 


iliar  ill 
pecial  interoi  n.lm,. 


II   k 


nown  that  in  animal 


more  partieulail 


tuberculosis  of  the  intestine 


s  e.\'perinientallv  fed  with   infected 


as  heen 


irod 


iiceii. 


s.  with  e.xtensive  di.sei 
ill 


of  t 


y  !i-  i;  i< 


milk   pniiMirv 


le  nieseiHei 


primary  tuberculosis  of  the  intestin 


iiestioii  will  be  referred  to  affiiin  on  ti 


es.      The  eases  fall  into  1 


le  ,L'l;il|i|., 
•^lilijccr  nf 


(1)   Very  slight  tuberculous  affection  of  a  f_      _ ,.,., 

ly  ones),  met  with  accidentally  in  children  wlio"have  (lieii 


our  irrniiiis 


on 


orders. 


ew  L'laiids  (which  i 


of 


liny  1)0  til,. 
v;irions  dis- 


(2)  In  the  chronic  generalized  tubercul 


osis.  in  both  the  acute 


pulmonary  tuberculosis,   and   in  the   more  chronic    forms  of  till 


liny  of  the  organs  in  children,  th 
and  caseous. 


ami  cIiiMiiic 
•erciilo.sis  nf 


Tl 


lie  mesenteric  glands  ma-v  be  foiiml  ciil 


lere  arc  instances,   too.  in  which   the  afteetioi 


teric  and  retroperitoneal  glands  with  those  of  the  tlior 


lll'L'Cil 
I   of   the  111|K(T,. 


1 


esioii. 


ii.x  constitiilcv  il 


In  both   tl 


ese  groups  the  disease  of  the  glands  d 


any  symptoms  pointing  to  abdominal   disorder 
(■>)   In  a  third  group  there  are  siLHi.s  of  clii 


,oes  not  neces-iirii 


V  (Vllhf 


ation    and    verv  marked    distiirl 


'11   chieliv   in   children 


irltanee 


in   tl 


'onic  intestinal  catarrh  nr  iilnr- 


le  general  nutrition.      T 


Il  CSC    CIlSl'- 


yea  !'■ 


•etween   the  ages  of  eighteen   moiulK  and  |iv 


ibdonien  is  distended,  tympanitic,  usuallv  a  littl 


pressure,  but  no  nodules  arc  felt.     Tlie  diarrl... 

toni :   the  stools  are  frei[ueiit.   brownish  or  yellow-! 


lainfl 


Idea  is  the  most  troiiMi 


ll    oil  llci'jl 


I'lllC  s 


yiii|i- 


mucus,  not  often  blood,     '{'he  diarrl 


•  I'own   111  color,  (■(iiitiiiiini:; 


for 
del 


liiea  is  variable,  and  may  soiiici 


several  weeks.      There  is  usually  slight  fever,  but  tl 

ility  are  the  mo-it  cbaract(>ristic'  features.      Tiie  name  liibi 


I  UK'S  ji(_'l'si>t 

le  wneriil  uii^iiii''  nml 


often  applied  to  this  condition.      Tl 


e  course  is  chronic  and  may  cMcimI  over  a 


I'O   I  t'BERC 

liiivfilvcd ;    thu.s 

;a.-fro-iiilestinai 

luiviilvcil :   in  li< 

Jivii„irkiible,  coil 

|w>c  of  the  stoii 

joM'S.     That   tl 

[(•\|i('riiii('iitiilly  1 

•iic  iW'diiig  of  ca 

IH'iv  many  series 

I  infected  through 

■liililrcii  is  lud 

|f;i>i'(iiis  foci  in  t 

i-iMiiccs  of  prill 

in  ;i  great  i 

yi'iici'iil  infection 

jfiiictiy  in  I  lie  ileu 

I  tiilici'des  may  bi 

|«iin|('  ilciiiii  max 

[iniduliir  iiiberch''; 

jiiiiK'oiis  niciiihrau 

I  III'  very  (•.\lciisiv( 

'I'voiid  ihcir  linii 

-"tninsverse  to 

It'L'cs  {iml  base  a 

11''  also  iiividved 

[tiili(>rck's  or  wdl- 

Priniiiry  tuber 

['•vtciisivc  iilceratii 

[(':is('  limy  he  rei.rar 

I !"  iiiy  wiii'ds  with  (i 

tliiTi'  weni  (iiilv  a, 

[cvii'ii-ivo  disease. 

jciivliii;;  ulcer,   the 

hvoi'iii-oiitcn.  and  c 

i'«astlii(d<  Mild  op 

I  111  tliwc  i,'irdlii,(r  I 


n  the  ^lainls  aro 
ffifiilt  to  - ,  ii„,^; 
iililc  is  til,  iiii;,,, 
rtof  the  <i,.n„„„ 
<  ii  positi-  !■  si^,,, 
■liiiMi.  uiil.-..  4 
liiliciilt  I,.  ,|,,|,,|,. 
.'rsciipiihii    ,sji;i,,, 

glaiiils  iiiviilv,,,! 
1  and  tl„.  ,.|,,||,|' 
eof  til,.  |H.|v,;. 
lus  of  1  -r,  ,.,.|s,,, 

IK'ttllTS  \\v\;'  ill. 
)OSt-lllo|-rcli]s  ,1,1 

ilecnitioii  mI'  iI,,. 
^l!"»il<:   .111.1  li, 

tllC    lll..-.(.|H,.|.|,. 

lor  tnli|.,v|(.s  ill 

ally  ill  iliihiniii 
icatcd  l,v  til;.-,. 
:la')ils.  'l.i.sii.ii 
■lii>^vii   that  i|„. 

illtcl-l'st   i.,.l;it,.< 
icularlv  ii^  i;  \,  ^ 

milk   jifiiii.'irv 
iciitcric  irl:iii/iv 

tli(>  sulijcrr  „\ 
'  ij;i'(Hijis  : 
•h  iii;iy  he  the 
of  variciiis  ilis- 


TUliElUULOSIS. 


tiirrii  111-  iilnr- 
Th('<('  r\<y< 
n\\\\<  Mini  five 
iiinliil  oil  il('|.|i 
bl('-i!iiic  sviii|i- 

or.  rolitllillill;' 

K'liiJU's  jicrsist 
1  wiistiii;:  iiml 

[•xtriid  ovei'ji 


111 

VMI'i'l'    two,    Ioadil|(f    to  til(>   mn^f    o..,f,.  ■      . 

;i,ffic„li  tod.tc.rn,inowlio    e,-^;  Lu^  [;;":,.l''''''r^'''"-      ^'   '^  ^""'<^^i'"*>«  very 
nnmc  del.iliry  and  wastin.^      J      |     d  •  ;  ,  /",  ■'"•"'  '"^■''  "  ^'"'""^i""  <'f 

l™-ie'^;i 

»vohvd.      IU.0  tlio  .liaiTlHca.     .OS     £';,:'  '"  "'"^'"".  *''*'  l-ntonn,n,  is 

..0  wasting  arc  as  in  tlio  provioi,    ™  •    ^  m  ;;:.,r''''"'^r^''''''  ""''  I"■"^'•^'^- 

w„h  disease  of  the  peritoneum,  in  vTiie  'no  ^vmptoins  are  assoeiated 

n.v  iH'  .-onsi.leral.le  ascites.      TJie  e    '.    ■      ■      >  ''"T'  T^  ''^"  '^•'^'  ■'""I  'iKTe 


li: 
iniu: 


,:,;,y  W  ..onsideral.Ie  ascites,      a^™;,;';  J  'V'  '"";--  f'^'  'h"  felt,  and  tliere 
nmler  IVritoncal  Tuberculosis.  "'  '■'^^"''■'■'*  ^^  '»o''e  particularly 

IMI-MIN,..,.    A.ND    OK   TUK    AnDO.MIXAL    ORfi.v.VS. 

('0 'rriiKucrLDsts  UK 'I'HK  liinvFi  s      'n 

'^"l-'l:    thus,    of   141    children    j^esen  ""l,  '^If "" 'r'""' ^'^"''""'^'y 

.:i<no-,i,iestinal  canal  (IJarthez  and  S-  '•  ■'';.'/"'';"'  ""^'^''-ations  in  the 
«'>"I^«"I:  i»  <i'»-  tlie  large  intesfi„e-  in  '  ,:  '"  ^"^l,  ^''^^  ^"'"'l  '^nt.sUnv  was 
M..,i.k„hle,  cons,derin,Mhe  con,,  n'ti  e  r^yul!  '!'.''  !"!''^""^'  "'""^■'  '^  ''^ 
V-  of  the  stomach,  that  in   t  ;  ie^  j '"    '    'l",  "  '"''!''  "'"  '"'-'■^•"'""■^  'li- 

c.es.  That  tuh..n.ulosis  uk  v  ,,  d  •  J  i:'"; ■'''  'l''^'^  ''^'^'■'  "'^'^  ^^ith  in  21 
«|»'nnir.itMllv  hv  tlH>  feedin.    of    n^  ■  *^   "•""entary  canal    is   shoAvn 

JlV.l.ngof  cahes  and^ 'l?,  1^^  ;;:|V^^T'^''  -'!"--  "f'  'l^^  hacillus  an.l 
..V  iiKiiiy  series  of  cases  U^hu  n  m  e  '"'^'''•^""V^"  •""'^-  '''''^■'■^'  ">■« 
":i-"''l  through  this  lattersou  ce.i'iri   ;•.;;''  'r''"''  "''"'i''^  "'">•  ''« 

:;:l"-r.;:t;r;;its^ 

,.,..1  ,.d.c;lo:r;^„;:\,i,r;i;'^,,:;;;-  are  part  of  a 

^li.^v  "Hlieileu!n,i,n-olvin,r  the  soli,.  ^..,;-'  ,  .'•,",."  '■"''^  ^'-''  ■^'t-'ft'd 
'"i'-clcs  may  he  seen  as  snu.H  n  u  io^  f  n'''  "i  *"""^^'^«""Vo.-.  The 
«!'"1<'  il<'".n  n.av  present  a  renm'       ]'  '  '"  ."""^•"•^"  =  .^"n.etime.s  the 

""'l"Ia>'  t„hcrcles,'the  L  ,  f  !  ] i"  /''''"^'''•''•'^•^^  *'■;""  "'^^  ^"•ayish-vellow 
«oi.s  i,iemhrane.s.  The  ca  it  an  ""''."''{'"f  ^''^  ^"''•""cosa  an.l  the 
!"■  vorv  ...x.cnsive,  inv,    in      1  ^^^w  ''"'  /"  "''■•'••"ti"".  "hich  may 

i-oiiii  ihcir  limii;.  'n  mh  ■'  h Hi T.r  r  '^r  ';;^  ""'■"^"^''>-  ^■^^^"■•'"'^ 

i-"tniiisversetothelnn/   xs     .3v      '^  It 

O'b's  and  hase  are  infilra'l^d; ..;;;:;':  ?  !"'   T^-"'"'-  '"  -^'i'-=    the 

»'■-''-  i>'-.lv..d  in  the  tulK^nlo  s  ;  .'Z^^^  '  nuisculari.s 

''■'"■'•^•''■^  '"■  w<.ll-marked  Ivn  n       ,     i        .  rfe        '    "'''^■\  '"'""'"^  "^^•"""S 

iVi.iiaiy  tiiherculosis  .d-'the  Ce  ^       "  J."  T'"'  ""  /'"  ''■'•'"'^•" 
•■^t^sivc  ulceration  in  the  ih    n        d\i l;    1      ?'  '  '■"'''•   '""  '"  ^•'''''''•<'"  ^^'th 
-"  niay  he  rcarde-l  as     r     ^     ^'lu  "^f^'^'r  '■'  ""'^■''  I""''^  ^'"-  ''- 
""".v^vards  wi  1.  dropsv  an  l-  ch  '•'"l;   aged  nin..  who  was  admi.ied 

•1"-  worn  oidv  a,  (l.    ^^n    1  f  '     ,       e  1      7  "")     '"7  "^  ^'"  '"""*''«'  -'•"•='ti""- 
""■'-ive  disease.        Vho  ,.   ,  "'^- ',  '''':'*"  ^"^  '"t-slines  showed  most 

'•'HiiiL'  ulcer.  theedJsof      ,1  ''     '"  '.'"'"''■"'""    there   was   a   lar.re 


il     :'l 


I'  :■  iJ 


Ihil 


^ih 


'■' 


I  I 


Hi 


:|     I 


112    AMERICA X   TEXT-BOOK  OF  DISEASES  OE  VIULDUEX. 

larn;e,  deep  ulcer,  wliilo  the  inosciitcric  iittiicliiiieiit  about  the  ileum  fur  ;i,.ti  ,,, 
liu-i^e  tuinor-niiiss  froiu  tlic  c\  iit  of  tiio  involvcMieiit  of  the  jj^laiids.  !'.!,(. 
peritoneum  presented  scattered  ubercles  and  the  mesenteric  glands  wotr  v\u<x- 
mousiy  enlarij;ed. 

In  a  tew  instanees  tul)erculous  disease  of  the  bowels  extends  from  a  ( iiionic 
tuberculous  peritonitis  in  wliieh  the  coils  of  the  intestine  become  matted  tmr,.. 
tlicr,  caseous  and  suppuratinj^  foci  develop  between  the  folds,  and  l)eii'iii;uii„| 
may  occur  in  several  phices. 

Symptoms. — The  symj)toms  of  intestinal  tiilierculosis  are  very  varied.  Thf 
most  common  indication  is  a  persistent  diarrlia'a.  It  is  not  always,  lunvevii 
proj)orti()nato  to  the  extent  of  the  ulceration,  and  large  ulcers  in  tlie  ileniu  imn' 
e.xist  wir!i  constipation.  When  the  ulceration  is  extensive  in  the  large  iiiiestinc 
the  diari'liiva  is  usually  j)rofiise  and  obstinate.  The  mode  of  onset  is  v;iii;d.|(., 
In  a  few  instances  of  general  tubercidosis  there  is  diarrlrea  from  the  siiut.  In 
a  large  number  of  cases  the  exist^iice  of  intestinal  complicatitui  is  not  MiMurt,.,] 
until  tlie  signs  of  disease  in  other  organs  are  well  marked;  and  in  |m;|i,||is  n 
majority  of  the  secondary  eases  tlie  diarrhdoa  is  rather  an  event  of  the  \mw\- 
part  of  tlie  illness.  Of  other  symptoms,  iuemorrliage  may  occur,  or  peiitunins 
from  extension — a  condition  not  very  uncommon,  and  often  assoei:i!e(|  witli 
disease  of  the  mesenteric  glands.  The  alidomen  in  these  cases  i>  iisiwllv 
enlarged  and  painful,  and  the  .odular  ma.sses  may  be  felt.  In  a  few  iiistaiKvs 
there  are  gastric  symptoms,  which  do  not  necessarily  indicate  ulceratidii  in  the 
stomach,  but  there  may  lie  loss  of  ajipetite  and  occasional  vomiting,  and  tlioiv 
are  uistances  on  record  of  profuse  luematemesis  or  mehena  from  ercisinn  i,f 
an  artery. 

The  outlook  is  unfavorab'e.  and  death  may  be  caused  by  the  se\eiitv(if 
the  intestinal  symptoms,  or  more  rarely  by  the  accidents,  such  as  perfoiatioii  w 
litcmori'hage. 

Recognition  is  rarely  difficult,  except  in  the  primary  cases,  wliidi  ire 
regarded  at  first  as  simple  entero-colitis.  Usually,  however,  when  wi'lUs- 
talilished,  the  diagnosis  is  easy,  particularly  when  other  organs  bcciJiiic  in- 
volved. In  susjiected  cases  the  stools  should  be  carefully  examined  for  tiibmle 
bacilli. 

{h)  TfiuatcuLosis  OK  Livi:h. — In  all  cases  of  acute  miliary  tiiliemilnsis  j 
granidation.s  are  found   in  this  organ  ;  sometimes  they  are  extiTuicIv  miiiiito 
and  are  only  detected  microscopically.      The  liver  is  usually  soinewhai  eriiiiivtd, 
pale,  and  fatty.     In    more   chronic   cases,  particularly  the  diU'use  geiieralizi'il  | 
tuberculosis  of  young  children,  the  tubercles  may  attain  considerable  sizcinnl 
develop  about  the  finer  liile-ducts.      They  underg'>  rapid  softening,  and  ;;ivi;i| 
very  remarkable  appearance  to    the    liver,  whi(di   is   in  extreme  cax's  aliinist 
honeycombed  with  tuberculous  abscesses,  varying  in  size  from  a  pea  to  aiintrblo; 
t!  .'  pus  is  usually  bilc-<tained. 

Occasionally   large,   coarse,   caseous    masses   are  founil   foriiiing   irro!;iil;ir  | 
lemors,  most  frequently  in  association  with   perihe])atifis  or  tuberciilniis  [r'h- 
tonitis.      The   so-called  tuberculous   cirrhosis  of  the  liver  does  not.  1  believe, 
occur   in   children,  though  there  may   be  in   chronic   cases  of  tuberculosis » | 
marked  increase  in  the  connective  tissue  of  the  oriran. 

('')  Tuiji-:rculous  Pkritonitis. — Tuberculosis  is  pne  of  the  inost  comrnnn 
causes  of  petritonitis  in  (diihlren.  It  is  more  common  ;ibout  theeiudi!!!  and  teiitli 
years,  and  attacks  boys  more  fre<",uently  than  girls ;  thus  of  80  cases  analyzed 
by  Barthez  and  Sanni^e,  there  were  from 


I  lie  ratio  c 

ties  1)1'  .Vldiber 

■iieii.     As  in  1 

i-iM'S  If  ]s   sec 

A  ilie  genitali 

Morbid  Ai 

«iib  ill    the   b 

limes  in  lOo  p 

i!ie  gray  gram 

Smietiiiies   the 

iiiis  tiiliercdes  s: 

'iftliese  varieti( 

'Icmiilly  jiost-m 

ilic  tiilierides   a 

firming   tlatten 

purulent,    the    i 

iliciii  there  mav 

cf'ils.  and  in  adv 

limi  (if  liu!  iiites 

iliesf  cases :   Fir 

siiiietiines  the  r 

"'liei'  eases  it  is 

iii;iy  lie  iiiulti-  oi 

Seconil,  then 

•'iinetiiLies  trom 

tivijiieiitly  by  tli 

AMibert  lias  foui 

Lastly — and 

nnibilieal  siippur 

I«ii'ti(in  <^'i  the  ah 

l'"i'iiied.  usually 

'|Niiitiineoiislv,  Ic; 

''III  iiiiiy  ultimate 

Symptoms.- 

wif'd,  and  it  is  v 

l'"i' convenience  I 

(1)    Tlir  A.rit 

|finiition  of  miliar 
iiii<tiiken  for  acut 
f'i''''liH'ntIy  the  oi:s 
M''-i'w.  indigestior 
piiiii:  but  in  man 
■tliesyiiiiitoni  for 
pieeeil  \u  ciinside 
tliosenf  grachiallv 
'"■'ler  tienirs  ii,  ,s,, 
''''"•'•bd'u  allernati 
^^'iiii'acteristie.     Tli 

8 


\^ 


TUBERCULOSIS. 


li\i 


1  to 

3  to      .., 

*!  to  lOi 

n  to  15" 


2J  yrs. 


.  11  cases. 

.  40      " 
.     9      " 


!  'mu  As  in  the  :u\n\t,  tl,.  .lis.a.o  ,  .v  .  '"'"''*''  peritonitis,  r>2  in  clul- 
.:i-s  ,r  is  secon.lury  t^  tulj^  ^i  '^^  '  '  f'?'  ^"'  '"  ^  "'"•'"••'^^  "*"  "'« 
.iilir  genitalia.       '  ^'^'""-'^  oi  the   intestines,  mesenteric  glands,  or 

I      Morbid  Anatomy.— Tnliercles  ii>  tl„.  ,„...,v 

»^tl'  HI  the  iMMlios  ot  <-l.ildic'  r,  o  ,  "'r'""'  '"r'"*  inft-equentl^  „,ct 
nn,es  m  10;>  pc>st-nun.,en.  .    "  i*^..  "'H^'i^?''-'«-  .J^^^^'-y  ""t-1  tlui  88 


I  n.nes  m  10.  jK.t-numen.s  on  luf;;;;.^,.  '  S  r"  Tl^:;'  •  , 

ilie^'iMV  -raimlations   witli    or  witlu.nt   ov,      ?  '    "^'ciir  eulier  as  (1) 

1^ -■-^^'"-:''tire^peritone„i:tnnd^;i^^^^^^ 

I, 


III 


N'--  vnrieries  the  j.roeess  nia  ^ hH      L         .  '      "'''''T^!^''  ^'^^"^      '»  '"'tK 

blally  i-ost-morteni.     More  f W.mu'i    v  r  "Wv  "'"'","  ''^  ""'^  "''''  "^'^•i- 

i:-  tuherHes   ai.  in   the  fon    o^  •,^'   :  l?"!?;^       •'--'--  !"--nt, 

™in;:    tiattem.l    tul.ercnlous    ,,la,  uos       T      t^',,!    "'•■"^''■''•^'  \"  *'"'"'''  "*'^'" 

F-mlent.    the   coils  of  intestines   are   m-.r I     ,     '^  >s    P'.rulent  or  sero- 

.l..n  ti,ere  may  be  large  <-as,.l;",.^:.;""', ;:;:;;•   /"^<''   -•'    -<l    ''^tween 

coils,  an.l  in  a.lvanced  cases  .■xtensiy,  „i,..,.,t    '.  "         ""P"*:'^'''l<'^  to  separate  the 

="'»  "f  II'"  intestine.     There  a  e  t hrL      '.^   '^      T''"'  '^''''  '"""'l*'"  '"■'•'•••'i- 

.I.SO  cases:   First,  the  efl^:;->   "layW         Z^    Cl'!.   ""  ^^T'I!' ^"•^■'••■^'  '" 

..netinies  tlie  process  is  confined  ]o    h     c-       ^  of  t  '     I''"  '        •"""  """"''  = 

'■tla-r  cases  it  is  in  the  j...Ivis,  less  freouentk   ,  V     ^''f, '^'^^^''' P^'ntoneum  ;  in 

.):av  l,e  multi-  or  mono  locular        *"''""'*'^  '"  ^''^'  "'"l^"^'  P«>-t'-n.      The  cysts 

..Sr\- !;nc;;;;:Sn  v^tt:^         ^^'^  "'^-^- "-  —tea, 

f'-ficntlv  hv  the  hands  of  connectiv  >  i  ^  f'"f  '?'"'"-'^  "'»''^''^^«  ^  "'«••« 

Ai.i;i^^..;i.sf.i.ndfiveinsLr:;';^i.^rri.:eh!;dr :r^^^  ^^  ^''^  ^"--• 
i™i'j:::ui;;;;!r;;;i'"'^hel;!;^^ 

l""''i'"'"''fl'''al,dominai  c.vi  it.;      ^'''•'  '"""'""'"f""  '-   in  the  central 

lit  iiiay  ultimately  heal.  '''. '  "'"'■''  P'^'''^''^t^  <'"'  '"onths 

Symptoins. — The    svinotorn«    r.f    t„i  i 

^•"^■•'■Hl  it  is  verv   lifli  •       t     'iv    ..     '•"'■'^■"'r-r    i':'''"""itis    are   extremely 
h''-v..,nce.th;.ce  cl,,:.l^^ 

l"iw„k(.n  foracut.  enteritis   or  ev  '-^"h'  onset   that  ca.ses  have  been 

'■'■'T'ontlv  the  onset  is  s,      ;„  ,1  is  "      i  "  r"';""?"   ''  ^"■'•'""-      ^I<"'« 

•l-^n..  indigestion,  and  ,  t       oia  ai^  r   ^T    '"^'  ''l"'^'''*''"     ^'^^■^•'-  "*'  ->"'« 

,  ^^'-  '-  -  n.ny  instan.: ''".Cs'  ^h  lent ''i  d '^  T  ''"  "'';'?""''' 
'^  'I'o  synipton.  for  which  the  phvs Cian  is  co  J,  1  ^l  '  M  :"';"'^"^.'^'  /'''^''"'"■" 
K">'""1  to  cMsi-lorable  de-r,-,..  ^vitho  ,    f^^v  1     "  ,       '"  ''""'""""  '"•'<'^''''  ""^y 

'^-"i>.:Mi,aiiy4ai,ingh;;,j;t;r^::;:;:;V^:L;^^^ 

■•'■'«  "imns  in  some  instances   iW-,,-,-]  .,,  '^     r  i     '^""*  '''fon.      Intestinal  di.s- 

r';-'"^ I'^'Hiatin.  w;;i:;:;;:^'±;:i''"'^,::"':'^'^^;i--'  -■  "^t-  attacks  of 

i  <;liiinictcri,sti( 


.  with  constipation.     Tlu-  l,,cal  sy-npton.sare  by  nomea^; 

t'eins 


Ti.ca.>i,.,.,o„i,ui,,,„;,„,:iL'*;,''^,;;n;r";;;s;-;,': 


!    1 


114    AMKRICAN  TEXT-BOOK  OF  DKEASES  OF  ('IIILI)RF.\ 

«'iiliir;:;tMl.      I'crcussioii  gives  (liilmss  in  the  flanks,  wliieli  is  niovabl 


in 


tl 


le  iiniliilical  i'e;,'iun.  tind   there  is  a  well-marked  fliict 


tion  niav  lie  entireiv  neL;ative:    no  nodular  masses  are  felt.     '1 


are  not  otti'n  enlarirei 


I.      [t 


unless  there   are  tuixTciiloiis   1 


niav   lie  extremelv  i 


liil 


le,  resi 
nation  wave, 
he  liver  and 


iiK'e 


>\i'{'\\ 


leiilt.  or  (|inte  ini|>n  -il,|, 


the  nature  of  tli 


esions   in  other  I'eLcioiis.  to  speak  defii 


III' 


,i:raiiiiall\--devel()|iing  aseite 


Tl 


le  clinieal  pieture 


similar,  indeed,  to  ihat  of  the  eases  of  aseites  from  cirrhosis,  and  a 
eondition  is  met  with  in  the  rare  eases  of  s 


V'TV 


le  aseites   may  demand  tapjiinir.  but   tlie  fluid  reaocuinuiate 


Tl 

exudate  may   he  enevsteil.   foriiiinir   a 
u 


iiiiple  eiiroiiie  peritonitis  in 


n  HI' 

eli, 


s  rapidl\      'I 


iivii 


...  .  „        Jironiineiit    tumor   in   the  epi^r; 

nii)ilieal  regions  (in  wliieh  case  the  etVusion  is  prohaldv  within  the  lt~s 
toneitni).  or  it  may  ho  situated  in  the  pelvis  or  in  the  flank,  and  simul, 
closely  cystic  ovarian  disease.      This  foi 


and  very  good  results  have  followed  operation;  of 


ni  IS  not  very  uncommon  in  cliilil 


>'ric  111' 
■II  jicri- 

llc  Vi'l'V 


ture, 


recovered 


Tl 


nine  instance; 


lis    ascitic  form.  ( 


(level 


in  tl 


01)1 


presenting  the  picture  of  a  chronic  ascite 
far  tl 


ng 


slowl 


I'CII, 
I''  lltclM- 


s  or 


operation 


in  encapsulated  exiidat 
lie  most  favorable  variety,  and  eases  may  recover  spontaneouslv 


y,  and  uliiiiuitc 


c.  Is    li 
"1'  ;ifk^ 


(2)    Thr  uh'n-atiiw.   f 


orm  IS  much  more  serious. 


Tl 


le  peritoneum  h.  i 


tains  larger  caseous  masses  which  break  down,  and  there  is  a  difluse 
peritonitis.      The  coils  of  intestines  are  matted  together,  nodular  t 
ma.s.ses  develop  on  the  parietal  and  visceral  lavers,  the  <'land 


larged,  and   in  ])rotracted  eases  extensive  iilcerati 


V  ciili. 
jILflllclit 

llhiivi|l,|||< 
are  givurlv  i.i,- 


iiis  occur.     Tlie  onset 
are  pronounced 


riii  is  usually  gradual,  but  the   abdominal   syinptoms 

child   complains  of  colicky   pains,   diarrlnra.  'and   chr 

aI;(loiiicn  is  enlarged  and  painful.   The  eondition  on  examinat , 

<lifl'erent  from  that  of  the  ascitic  firm.     The  outline  is  often  svnim 


ui  li|i> 


flatt 

.skin. 

tluliK 


ened  in  tlie 


L'nh 


flank 
tl 


chronic    indigestion.     Tlio 

ion  may  be  eiitiivlv 

letriciil,  ii,i( 

•eiieiitli  \\w 


s  ;   nodular  projections  may  sometimes  be  seen  1 
ess    there  is  a  very  extensive  purulent  effusion  there  is  no  movil 
flat 


ess.      Ihere  is  a  flat  tympany  or  there  are  alternating   areas  of  ic 
iuid  diiliiess.      On  jialpation  there  is  a  boggy,  doughv  feel,  and  nodiil 
may  be  felt  in  dilfereiit  regions.      The  liver' and  spleen  niav  both  1 


'lll,-|l|C(. 
!ll-   IlllhSI'.S 


In  tl 


is  suppurative  form  the  effusion  niav  be   •nuieral.  or  it 


le  ciil 


niav  be  ciicv<ici| 


either  in  the  upper  abdominal  region  or  in  'the  pelvis.    One  form  o'f  this  ciic'v. 
suppurative  yavietvj-eijitires  sjiecial  consideration — namely  : 

hxn-HH. — This  is  seen  most  frequently  in  clnl 
suppurative  peritonitis,  which  poini- 


'rrii(iiiltllle<il  Ttihcrruliim  Ah 

lized 


(Ireii.  and  is  in  reality  a  loc;i 

navel  ami  fre(|ueutly  opens  and  discharges.    'I 

tuberculous  in  the  c'hilil.     There  mav  lie  a  fist 


t  tilt 


he  condition  is  aliiio.-t  cniistiiiiflv 


le  a  hstiiia  discharging  pus  f. 


months,  and  recovery  may  ultimately"  take  place.     In  ot 


communicate 


wi 


th    the    I 


lier  instaiK 


)(iv,e 


tl 


r  \vc( 
iIk 


le   case  o 


a   colore! 


I   child. 


list 
ti 


iii;i 

Vf, 


operated  upon  by  my  colleague.  Dr.  Ilalsted.  there  was  distention  of  tlir  ;iIm|,. 
men.  marked  protrusion  of  the  umbilicus,  and  here  a  spontaneous  n|,(.)iiiiL' (lis- 


charging  yellowish  material   for  niontl 


IS. 


Tl 


len   tlie   opening   healcil  ;iii( 


condition  of  the  child   improved.      At  the   time  of  the   operation    il 
large,  prominent,  cone-shaped,  umbilical  tumor.     The  child  died 


till 


tl 


ere  WIS  11 


soiiu'  tiiiK'iiltcr 


operation  ;   creamy  pus  was  found    between   the   intestinal  coils. 


Avere    many  tiiberciiloiis    ulcers  in  the    intestines.      There 
caseous  salpingitis. 

There  are  instances  also  of  perihepatic  tuberculous  abscesses. 

(8)  (Viro))!)'  AiDiPKli'f  „>•  f)ri/  TiiI'iT''}i!'.!Ux  l*,>ritiiuifiit. — Iji  a 
alile  number  of  all  cases  of  tuberculous  peritonitis  there  is  litt 
or  purulent  exudate,  but  the  tubercles  are  surrounded  with  a  ti 


:ilii| 


Illi'lV 


was  ail   I'Xtt'ii.sivi' 


n  a  vi'i'v  consiiliM'. 


e  iir  110  serous 


iiiii'iiis  Ivniiiii 


Her  is  in  itself 
miiiiy  (if  the  case; 
The  condition 
ami  fniiii  chronic 
pie,  is  a  rare  disc 
kt  alter  withdraw 
uiiiisiiiilly  hard,  an 
lar.    'flic  general 
fi('i|iieiitly  a  slight 
ii"i  sii  marked. 
Hiii|ile  chronic  per 
e.\|ilorat(iry  laparot 
I'l'  siiiiill   nodular 
hin|Hirtaiit  in  these 
'ii'ilee  to  determine 
filiioiil.  the  experin 
iiMaiiecs  of  report( 
Iwc  been  instance 
['I'll'' iileera live  foriii 
[ill  tlie  |ioritoneuni  w 
'iiffii'iilty  in  diagnosi 
'"I'liis  also  may  be 
li>tiila.  simple  or  st 
Prognosis. — Th 
'■'ii'i'iiii'  iidliesive  va 
ii'i^  jrniiliially  di.sap] 
i  );ii''<-'t,v.  wliei'i  the  al 
"i*'|||H'i'iitiiiii  of  inci 
.<!i|c-il,|,.  niiiiilicr  of 
Treatment.— Tl 
tlieeiiilof  the  sectio 


TCliEliCULOSIS. 


115 
indtLey  tend  rapidly  to  cicatrize.     The  m-owiii-  fnl.m.  1 

,l„lt.s  l.aH  „ften  hoen  mot  with  i,.  ex   I        ..i  v  ''  .''"^^:"""'f^'"'-  '""l  in 

m^.     In  lo,..-,standin.  eases  te  SxZaPJTTT'  ^'""  ^'''•'""^  ">'"''- 
lovacply  pig,„onfed  fii;;„id  adh  ^U  ,     o    !  S'h   '^'''•''  '•^"'  -"•'-"-l-l 

dusisof  the  peritoneu.n  is  localized -th,  TZ  t  7  "^^^^^-^>\  ^l'^  tuher- 
aUc.  nr  i..  the  regiu.i  ,.f  the  ciecfm, 'a,  ,  i  *'"  '"'I'''^  '"  ''  ''^•'■"'■••''  '^"c 
a.v  iN^ta,.ces  in  ^^^.ich  thrnn.r  I  ''''/'  '■  "' ^ ^^^  ^'''■'•'•"'"-  '''''<■-■" 
until  :•  fonns  a  ri,I,H>-Iike  tu,  'i' "  ..^  l.    I.''''  '"■'"'"""•^:  ""•'"'  '""'  '•""-' 

^'"^  '"-"i«-  -nK.;:ive  torn,  is  n  i  S  iJ  Xnt'in''TT.'"""""  ^'^"  ^''-''"'•'•"<'"- 
»n:i)t''nis  are  very  indefinite       Tl„     .1  i  '  ^'''il.lren  as  ,n  adidts.      Tiie 

■' 'i'^' » r™-  ■ri- so„..,.ai ».4, «,™  r ' '  's;'!;;;. "'•,;"''"■'■  ■""■''?" 

wistin^'  and  cachexia,  sometimes   with  .......l-        ••    ^'^"'V'*-      "'<'''«  niav  be 

forn,.s  are  not  intC  -mlT    e      h  7         7'    '''""^'''    '''^'•^^^  •^^''•'""i^ 
"ay  be  subnonnal.     "^^ ^!:':t3;r^r:  ^j'-  ^-M-ut.:re, 


II    e.xtcii.sivr 

1 

Y\  (.'niisiilci'. 

1 

ir  no  scrolls 

1 

111  HIS  lvill]lll 

aiilicxivc 

iN'l.eil.  n,ay  be  subnormar'SvUhM!;'' v!^  t">-ou»J,ont.  or'the  ten.perature; 
«y  Ik.  no  .;yn.pton.s  direct  v  fro  ,  he  e  it?  '  f  '\'  '■°^'^'^>'  P'''''^  there 
.inp.i,.ated\vi/h  tubercles  1  X  ^r^'^';";:;;'';;;'"^  ^'-;--  '-0  ve.y  often 
l«n?s  may  be  exten^ive]v  diseased        '[i,  "'♦^^■'^^'nteric  jrhuuls  or  the 

Innivcrv  is  not  infreciuent  "  .ureases  m  which  spontaneous 

.an.  .if  the  ,,„o,  „(■  »i,r,J    .    .i,.,      ,"'"''  "'""■';";l'»'i»-     DoiiMI,..,  von- 
il..M.on.liu«,M«  ,„  I,"       ,i ",';,,  '      '■""•■"'y    '<-■ S  I"  tl,i,s  ,|i,<,„,,,' 

|J.'.  IS  a  rare  disease  in  children.      The  loe-,1  sv  11  '  ■\M.''"litic  or  sim- 

Init  alter  withdrawal  of  th,"  fluid  the       ,.,     .      •^^"  Pt'""'^  "'-'y  jrive  us  no  v\nv, 

b.     Ihe  ^^eneral  svmpton.s  are  more  imn..rt  '         r  ^''.^^  H"l'«.  'm-n- 

-'-  -narked."  Ai  one  •  ^d  exmh^  X  f  •"T'"'*'^^'!'"'  ^^"'''^"•-  "'- 
^nnplo  chronic  peritonitis:  tho  ,'h  t  ^i^i^  n  Hi""'  "^  ^;''-'-'''-i^-  A 
"I'ioratory  laparoton.v,  the  dia.Tnosi     ,;  -      '   ,     ,  '''''''■^■''-  ""'''/'^■^■"  "ft^''"  tl.o 

"'•^'"""  '""'"'"••  «'''-i'l  '-<ii-  s  at  '  d  ve  ;  !'■;  ''''r'"''''' '"  l'''''"^  •'''':^ 
iiupoi'tant  in  these  ,,,s<n  to  inv,.  ■,  ,...    •  '    niembranes.      It  is  verV 

l-todetennine  tie  p   it^;  ,7 f   ^  I  ;7'7;;P-1  <;— "t-  -'.le,  in 

fil-i'l.  the  experimental   t.-st     h    d  ;,    |e      ";'-""'"'"  "''^'  ^■"'••^'  "'•'"  """1 

'n>'an,Ts  of  r,.ported  .•ecoverv  i         rit    ,  ,         ,"  ■'"'"  ''"'^'^'l*'"  t^'^^t  ^'»>"o 

'-'■  '-'■"  ins/ances  of  th    ^    J  j^'^  /''''•"'r''^:'':'^  after  laparotomy  n.av 

■'''"■"''-'■••"-■•-■  fonn  "ith     npp        i  „  H,  !'T""r '^  ^^"''   "'"•"''>    "-Inle.s. 

,„,|,,,,„,i,„.„,„„  ^^.^,,  fr,,,'        ''.'':'■      tlio  development  of  no.Iular  n.asses 

'!'«i"""ty  in  diagnosis.      It  t  .    i  J,     ."f  "^f ''  '■'"■^■'^;  "«^'''^  ^he  slightest 

'■■™^  also  n.av  be  en-^vsted     •.   d    tl  .  /•  ■"\"'''';'  ^'"'^  t>'^' ■^"■M'urative 

I- .irmilnally  disappeared  have   Ihv     tn  J  '  "•  "'  "''''•''   t^'*"'  "'^^'it^''^ 

;:|™y.  when  the  absecss  In       li  e|     •.  eJ^^^ b      '  ""','  '"''"  '"   ""^  "''''^'-"tive 
"'•■"l'"''"i""  "f  incisi.m  an    ,1     i,        i  '"•  '!"'''''•  '-e'-'^-erv  has  followed 

*l,l,,.,,;,i..  ,„„  ,     '"^'•"""1  and  diaimi,iie  has  certainly  favored  re.^  ,ve.-v  in 
•" 'I'"'  niiiiilier  or  ca»es  '    "'-"'"  "<o\eij  in  a,  con- 


^^■ 


116    AMERICAN  TEXT- HOOK  OF  DISEASES  OF  CIIILDUEA. 

ion  and  (lrainii<;o  in  tiiberculouH   poritonitis.      The  results  wliich  Imv.    in-en 
obtiiinod   aro   excecdinf^ly  satisfactory,   even    if   wo  siipijosc,  as    is   [jk.    il,f,, 
that  many  casos   relapse  ami  are  not,  fully   liealed  at  tlie  time  of   rep  m,,,' 
The  fi<rures  j,'iven  in  the  iiionoi;rapli  of  Aldibert  aro  oxtromoly  intoresii.  ^':  J^j 
the  ascitic  form,   of  ;J:i  instances  in  wliich   lapiirotomy  was  pcrfornieii,  ihciv 
were  8  deaths  and  "JH  recoveries.  4  of  wiiicli  had   persisted   for  more*  tlim  „„, 
year.      This  demonstrates   the  impunity  with  wiiieh  the  ahdomiuid  caviiv  nmv 
be  opened,  and  the  larfre  percentage,  at  any  rate,  of  those  which  are  bi  iiclit,.',, 
innnediately  by  the  operation.    In  tiie  chronic  adhesive  form  an  operation  i-^  iv.ijlv 
not  indicated,  as  in  the  majority  of  the   instances  \\w  tuitercdosis  is  m  wl. 
cessof  healinj,'.  but  there  arc  cases  in  which  pain,  associated  witii  the  adiicsidns. 
has  been  relieved  by  an  exploratory  incision.      In  tiie  ulcerative  varied,  w|h.,| 
f^eneralizcd,  the  results  have  not  been  so  satisfactory,  but  many  instatiics  wi,|, 
an  encysted  purulent  fluid  liave  been  opened  ami  draim'd  successfidl\.     Tlic 
draiiia<fe  favoivs  the  process  of  cicatrization  in  the  tul)ercle,  lessens  the  irinlcncv 
to  Ltfusion,  and  exerts  a  favorable  inllucnce  on  the  whole  process.     Of  il,,,  ;,'o 
cases  in  children  in  which  laparotomy  was  performed,  there  were  4")  rcci.vciic" 
and  7  deaths,      (►f  these  4-"),  !»  jiiul  persisted   for  mor(!  than  a  year,  aii.l  -.'tor 
more  than  two  years  (Aldiliert). 

{•"5)    TtHKKCl'I.OSIS    OK    TIIK    Tii:X(iS. 

In  speaking  of  acute  miliary  tuberculosis  and  of  clironic  diffuse  tiihcri'nlosis 
we  have  ciuisidered  affections  in  whicii  the  Iiinirs  are  almost  constiiiitlv  iiivulvcil 
— in  the  one  case  tiie  setit  of  miliary  jrriinuies  ;  in  the  other  of  ];ir(r(.r,  ,.,|;,|.,|. 
grayisli-yellow  tubercles.  We  shall  speak  in  this  section  more  particiilarlv »!' 
those  forms  in  whicli  the  lungs  are  so  involved,  that  the  cliiiical  feature' 
those  of  an  acute  or  of  a  chronic  pulmonary  disease.  Two  groups  of  cuse.^  mav 
be  recognized:  the  acute  tul)ercul()us  broncho-pneumonia,  and  the  ciudiu'o 
ulcerative  form,  the  first  corresponding  to  the  acute  galloping  piitliisis,  nml 
the  other  to  the  clironic  phthisis,  or.  as  we  call  it  now,  chronic  pidiiKniurv 
tuberculosis. 

{(t)  AciiTK  TiMiKRCULoi's  Bkonciio-I'Nehmon'ia. — 111  infants  iind  d -Mrcn 
we  very  rarely  sec  pidmonary  tuberculosis  .set  in  with  the  clinical  pKtiiivnt' 
an  acute  lobar  pneumonia..     I'ersonally,  I  never  remember  to  iiave  iiici  with  ;in 
instance,  such  as  is  not  very  rare  in  iidults,  in  which   the  tuberculosis  ciiiiiciiii 
abruptly,  and  at  first  ran  the  course  of  an  ordinary  lobar  pneumonia,  with  iiain 
in  the  side,  high  fever,  and  rapid  consolidation  of  an  entire  lobe.     Sik 
are,  however,  on  record,  and  it  is  only  the  absence  of  the  crisis,  tlu 
of  the  local  signs,  tlie  irradual  softening,  and  the  development  of 
progressive  deliility  which   lead  to  a  revision  of   the  diagnosis, 
rememlu'red   thiit  wliiie  clinically  the  physical  signs  mav  be  thos( 
aflection.    anatomically   it    is  clearly  seen    that    niaiiv  groups  of 
involved,  separated  l)y  strands  of  iur-containingor  colla|)sed  luiig-tis<iic.    Those 
frnvwhi-hhar  cases  tire  almost  impossible  to  diflcrentiate  during  lite. 

Tuberculous  broncho-pneinnonia  is  common  in  children  from  the  sixth 
month  to  the  fifth  year.  .\  large  proportion  of  the  cases  occur  nliri-  the  sec- 
ond year. 

The  disease  is  most  common  in  children  in  institutions,  in  tIios<'  d^hilitiiti'il 
by  previous  illnesses,  and  more  particularly  in  convalescents  from  one  (if  the 
mfectioiiH  diseases — ^lucasles,  whooping-cough,  scarlet  fever,  or  diiil'titeria.  It 
is  most  fretjuent  perhaps  sifter  measles  and  whooping-cough.  \\^  ■..■.|ii<'n(Tin 
the  latter  disease  has  been  common  knowledge  in  the  prof'es.sion  si'  ■!■  the  dii}'3 


ire 


I   CIISl'S 

|icrsistciice 

lirctic   ;|l|il 
t     is    to    111' 

111'  II  hiliiir  j 
'lilies  lire 


n  ! 


U 


TUHKRVVIAJSIS. 


117 


l/\Viilis,  whosf  axiom, 
lliroii;;li    two   ct'i 


uses 


«taH.  and  tonsillitis,  and  nJ     h-  r      In"  '  :;:  ./l;:'''""''"   "-VP''-7"«eal 

,:4;d  sjii-r-'--'  '-^  ^^  ^'^^^^^^:^^:^:'^. 

d.iiMis,  or  the  ,.ro^a.nit.|  trac-t  parts-the  skin,  bones,  lymph 

I     Morbid   Anatomy. — Tlic  pon<li^,■„l,    „     • 

L;n;,n,idm.utionortl!;:nroc;is  "n  !  '.r  '  r"^'^''"'''^  ^^'''''  "'^'  '"'''»- 
Lh  tinu  and  no.luiar  n.Lsos  scatter.!  t!  ;;nS  U-riob"'''' o/"'  T''?"^' 
hresH...  to  I,(.  ,K-nbroncliial  nodules  ran.^in:    n  s  !'  V  ,  ''*'^'""  ^^'""^ 

^i.l..  P-l.aps,  central  softening.     ^A^^^t^^,,  '"•''  «••"^'^•'- 
I  :.;:.'  .r^:!^'/^  aggregations  of  tubercles  i.  le 


«iaj,iMi-_velloW, 

oneliial  nodules  are 


i-"""  "t  the  lungs,  certain  parts  of  ^vlucl      uvi;.    „,'''' 1>'' T'' '*"'^''"' 
Mitain  anvair.     Tlio  con^olLbitio.,   ,„..,  •.         ,       ^  ^"'"'  '""'  s^^arco  y 

...noted -that  t!..  proeel^ls     i         n    j  V   I'm:"'   ^"'^'^   "7'^''"'  '^"^  «"  «^«''"» 
d,e  general  consolidation  l,as  ar    J  "  t  f  "^!"  T  '"  '  '"•;'"■  I""^'""'^"'^'  l>-t 

Ikof  the  lobules,  groups  of       .j'  1,  !      '»  'o  ven.ent  of  a  very  largo  num- 

lapsed  tissue.      Tlie^.nidilted    ,1^^  "r;/;^?     '^^^  ^"•""<'^<'*"  '•-l<ii«l>  col- 
place,  have  softened,  fo,.n,in..  caviicf  'i-  !  "''''■^;""^- <-a«'at.on.  an<l  n,av  in 


■  places  have  sottened,  foi'uiin.'  cavities       'I'l,.  ,>l  i      fi        ^ "•"^•'"""-  an<«  may  ii 

;.ve  usaally  are  the  ,reas  of"ca  e    i.n       T  "'  "!'  ^'"^^"^  ^''«  •""••^'  ^"-^^^^ 

ofiheso  oases  show  a   ndxed   inS^n    an .7//  P'-""'"-''V"^'^™"^«"^' """^^ 

LnmclM-pnoumonia  <lue  to  ^  e,  tococd    J  "'''   '""^  ^'''  '"'^"^  «^"  ^^i'»I>le 

pleura  ,nav  show  n.anv  nodu    s  •  Jb  '^*:T''.^''«^"^«''  "''  pneun.ococci.     l^he 

JLnous  ;,r  even  purulen    ex^^,    ue  ^'^-T,!  '  ^f""'*"'^  'j-^'-'afN  -.n.etin.es  a  sero- 

.ia,,o.l.  tumefied,' and  stu.ld      .  th  tu      clts'or  ^  f'"" V'"'""'""'  ^''"'"'^  -- 

lliantiv  having  softened  to  form  .1  .fi   i  e     £ce,s      t  .'    '^  "^'  '"*'"'■ 

lD,ayl.e.reatIv,.nIar;:e.lan(lex-temlde  ,L  ,  f  ,,^ ''f  ,«l"n^l«  at  the  hilus 

I'lancos  there  would  anne.,-  l^ZT^^'^l  ''^^'}^<-^^n.  »'e  lobes,  and  in  some  in- 


cliitis  an.l   peribronchitis   excited  bv  the'V,;L.V'r  T^"\':''  '.^"^'on  '^  a  bro: 
lofthecontim.ous  ni....ells   ^vl   '     w/,      *" '^^^^''^cdli,   with  inflammation 
^iti^     T  '    ?       '     ""^  ^'f'  ^V^^\^^YvA  products,  the 
'!<  i«.     J  he  accompanying  phenomena  of  a  electasis  and 

bt'^rLz  H352? -r^^^^^^^^ 

l'"'ks  simple  in  character,  is  iiavtuL  ''"''•  T]  ''''"'',  '^'"^^""'i'^'^lly 

'"")■ '"'  dillicult  son.etim^s  to  de  o  ,nin  """    ''"'  ^'^  *^'"  ^"^^''"i-      It 

Ip-nnonia  is  tubercuh.us  >r  1     b  / '  T,"  ',1   T  '  '"''"  'T/*"'''  ;'*"  ''••«"^''«- 

I'e™  .small  tnbercles  or  areas  of  caT.;' ;    '      '  '.""^'•"^^■"P'call.y,  there  will  be 

^■eroadilv,len,onstrable      T."    2  :      "'  ''l"''^  '"  •'^^''""^•^  '^^«i«n«  the  bacilli 


i"d)lp      'ri,<.    •      1    ,  '  '"  •  """^"'  **ecnons  1 10  bac  Hi 

al)0.      lie  simple  hroncho-pnoumonia  in  some  cases  nre 
IS,  particularly  after  measles,  scarlet  fever  .liXheria   ZT\ 

r^>'i''iH..,,,,,.,,o.p::r;ar::::i;^r^T'T7^"'"r?^^^ 

"^••'"1H"1  pnm.ing   to   fre  1   i      ,r  :  ",'  •'"^''^;  '''"'^  ^''^^"  symptoms  have 

'  ^"^^'^''''Jus  broncho-pneumonia.     Somnfim.^  .i.. 


;  (i 


'.% 


lis     AMKlilVAN  TKXT-lUKiK  oi'  DISh'ASKS  OF  ('llILl)lil: 


infection  is  less  inti'nse,  and  a  subnciite  or  cliroiiic  pulinoiinrv  tulnTi 

cstalilislioil.      Ill  ciist's  of  tiiliiTcuiosiH  conMiTiitive  to   ))roiiclio-|iiicm 

wo  sorts:    siiii|ilc,  iiitiiinmiatorv,  iion-tiiliciriiloii- 

liiTiliroiicliial  siip|iiiiatioii.  dilalalioii  of  the  hrdiiclii',  li'siuns  uf  rlio  alv 

tlu'limii,  and  |uTibroiK'liial  and  pcri-iilvcolur  sflciosis ;  tlicn,  in  addit 


find  tlic    i('si(iii>  of   t 


at 


o  tlu'  trill'  tiilioiTiilous  procfssi's.  ]K'i'il)i'oncliial   iiodiilcs,  tiihcrci 


II   lllll  w,. 
i'"i.  tlicr,. 


tion,  iinil  caseous  areas  (.Mosnv) 


loll-  iiihlin, 


In    otiier    instances    tiie    tiilierciiiosis    precedes    the    hronelio-pni 


Tliis  i.s  met  witli  particularly  in  cliildreii  tlie  siiliject  of  latent  tiilx 


illllllll; 


whom,  followinj;  one  of  the   infectious  diseases,  a  simple   lii'onrhn-] 
develops.      Accoi'diiii,'    to    .Mosiiy,    the  lesions    mav    In 


rciiiiisi>, 

"■   HllKllil;,! 


seen  as    an   nU 


siiiTomiiuin.'  the  tiilicrculoiis  perilirunciiial  nodules,  or  foci  of  sininl 


coliii. 


C'liloiis   liroiiclio-piicuiiioiiia  ticciir  scattered  throujrhout   the  apices  of 
piieiiiiioiiia  dependent  upon  pneiiiiiococci  orstreptoci 


e  mill  till 


IS  a  iiroiicho- 


It 

11  lull''  alreatlv  tlie  seat  of  local  tiilierciilosis 


ih( 


lllll:' 


■I  iiiv;i(|ii|.. 


Symptoms. — Clinieally.  tiiherciiloiiH  broncho-pneumonia  scareelv  i\\\l 


any  feature  from  the  simple  form.    'I'he  onset  may  he  acute  in  a  previous 
child,  hut  iiioi'c  fre(|uently  the  disease  sets  in  duriiiif  coiiviilesccuce  from 


infectious  diseases.      In  the  ti 


ihei-.Mi 


loiis  fi 


ITS  ml 

l.\  lll'llltllV 
'UlCdl'tlH. 


orm  the  tever  is  sonietimes  iioi 


mid  not  so  persistent,  showinir  imue  variations  throii^dioiit  the  day.     ( 
dyspnica  are  proiniiu'iit  symptoms.      Tl 
imeiinioiiia.      'I'lu 


liL'lil 


ali/atioii  of  the  Icsioi 


jiliysical  sijrns  are  tliose  ol  l/r(iii,.|„ 


|||iL'li;ni 


tiu'  luii<'.  where  there  mav 


I  IS  more  coiiimonlv  at  the  iiiiicc 


le  siir 


ns  of  consolidation  with  Hue  ercpitani  atiilsiili.l 


crepitant  riilcs.     There  are  no  physical  si^^ns  of  any  moment  in  ditlci( 
a  simple  from  a  tuherculoiis   Itroiicho-piieiimonia.  and    indeed  even  il 
ization  of  the  disease  at  the  apex,  upon  which  so  much  stress  is  laid. 
very  much  value,  since  we  freniieiitly  lind   in  yoiinj,'   children   a   ml    .. 
process  hejiinninii  at  the  hase  or  in  the  central   portions  of  the  \n\vz-     I 


iitiiiiiii,' 
II'  liii';i|-| 
is  iioti.f 


it'r('iil"iis 


course  of  the  disease,  however,  indications  of  iri 


11  'lifl 


the  end  of  the  second  week  tl 


eat  va 


lere  are  more  ma 


liie  develo]);   thus  towiiril 
rked  oscillations  in  teiii|icratiirc 


often  with  profuse  sweats.      The  child  emaciates  rapidly,  and   there  iiiiiv  suin,.. 
times  develop  signs  indicating  softening.      In  the  acii'te  cases  the  ilunitiun  i. 


from  three  to  five  weeks.  Throughout  the  course  id"  the  d 
no  single  iiulication  of  much  value  in  definitely  determiniiu 
often  have  to  depend  more  on  the  general  features  of  tl 


isease  tlieiv  iiinv  lie| 


tl 


le  nature,  anihve 


I'les   slioii 


Id    h 


le  case. 


(' 


ma< 


le  as   to   heredity  ;   also   the   personal  hist 


liretlll  ii|.|ii|. 


orv  iiiiiiu'ijiattlv 


iVIll 


precedm^L,'  the  onset.      .Sometimes  important  information   may  he  gallieii'ii 
systematic  examination  of  the  child.      There  may  be  a  till 
local   bone  disease,  or  a  tuberculous  test 


lerciiloiis  iKJciiiiK 


IS. 


Simi 


.is  a  rule  to  recovery :    in  exceptional  cases,  however,  it  beco 
ultimately  clironi''.       In    the    more  subacute   and   chronic    ca 


(ronclio-pneiimoiiia    may  presi 


nt   li 


irge    areas    ot    caseation. 


pie   lironclio-piiemii'iMia  hw 

iiies  siiliiiciitc.  aiiij 

ses    iiihcrciiliiii* 

ilie 


physical  signs  of  consolidation,    perhaps  of  an  entire  hdie.      In  su. 
sid'tening  and  the   signs   of  cavity   not    infreipiently  develop,   an. I 
f  the  nature  of  the  iirocess.      As  the  little  | 


defii 


lite  indications  o 


wliicli    i.qvt'  ilie 


I  iiistaiirt'S 

L'ivc    VflTj 


latii'iiis  rarelv 


inH'tiincs.  I 


expectorate,   examination    for  bacilli    can    seldom   be   made 

vomiting  occurs,    portions  id"  mucus  may   be  picked  out,  and   iiiiiH>itiiiit  cvi- 

•h'lice  in   this   way  obtained. 


niiicli  may  bo  ( 


lakiiig  its  origii 


(7/)  ('llKuNic  Pfi.MONAHv  Tfiii:i!ni,os[s.  —  Tn  infants  and  w'ry  Vdiiiii;! 
children  -ve  find  the  lungs  either  involved  in  a  generalized  tuben 'dosis  nrtliel 
seat  of  an  acute  tubtn-iiloiis   bronclio-]»iieuinonia.     After  the  siv  !i  or  dgli 


TVJii:ii<'rLONis. 


uar  luwcs  arc  not  very  iiticnt 


lironic  tiil)('iviil 


iiiiH.ti   in    wliicli    tl 


(ISIS  piiliiioiiiini  oC  ||„.  adult. 


0  picture  resembles  that  of 


Morbid  Anatomy. — The  1 


(■iim.«is  ot 


alW.-  i> 


r  «:^;;.::::^^i:v ';;=:''':::;;:*■::". V'"-"-  ■-'■  ■ -..w 


f  sof'teiiiii;r  n,„l  „f'fil,n.i(l  ii„| 


||»'i'il>i'(incliiiil   nu(|ii|(.; 


The  t 


St 


liii-t 


'e  so  CnMiiifmlv  tiic   inv 


iiralion,  and  cavit 


cs  of  vari 


liisooiiM    liloelvM. 


liii'  liase. 


fi'liirL'i'i 


soat  of  di.soa.sc  niav  I 


i'SK.n  of  till"  liin.r  from  tl 


"US  .sizes. 


w 


vs  It 


Iroad 


y  inentioiied  in  h 


H"  ill  the  central  |M.rtion  of  tlic  1 


>L'  a|)c,\  downward. 


tlu"  j,'r()iips   aloih'   tlic   trad 


pea  km;:  ol'  liiiioivii 


and 


cascoiis. 


"•'  "'"'  ••''""<f  tlit'  hrondii  niav  1 


•I'lj,'.  or  even  at 
"^'is  of  the  lymph- 


'"■■lun^'on  section  a  very  striking  f 


>e 


frrealli 


I'atiiic  111  the  cliroi 


piiiniMi.ary  tiiheiciilosis  (.f  ehildreii        Indeed  ^•„  ^- "c  ciin.iiic 

-..IS  .0  spread  ilirectly  from  t le   h.,,!        •     Id     .  77-  ''TTr    ^''"   ^'''''''' 

vl,i,.l,  l.ii.v  l.omw. r.l ,    .       '"l".\l''-'</''l.i:l!lll.is  111   lliehllllS.d'th,.  1»„„ 


niiicii  II 


my  be  onornioiislv'  enlarired.  iiniforml 


iliiwtly  inyaded  from  tliein.     I 


;i|iill,  ;ilii|  o 


ften 


present  foei  id"  softci 


'fir;,'!'  areas  of  casei 


y  caseous,  and   the  oi^ 


1'  the  lung, 
•111  may  bo 


ling. 


Miial 


'IIS  pneumonia  are  not  uiicon 


Hint  111  chronic  imlnionary  tuberc.dosi.^of  ehildreii.  I 


ca\  ilie.s  are  by  n(i 


means  infre- 


aiv  i'iir( 


tl 


Ills  in  the  l'( 


ibes  with  excavation. 


»•)  cases  noted   by  Haiti 


'lit  very  large  excavat 


ions 


Lcrou.x  0 


f  til 


clue 


Hy,  t 


o  cases  of  the  lute   l'rof( 


"o.   111   the  nil 


K'Z  and   Sannee  there  were  77 


I'liis  (if  age  there  wei 

lif  c'liildrcn  were   under  th 


per 


e  -•>»   instances  in  avIi 


essor   I'arrot,  in  21 H  cliihl 


1.1   till'  analysis   b 


i  tiljrous  tubercles  are  found,  and 


.'ee    months.      Ii 


.cli  cavities  existed.      1 


.•en   under  two 


bidii  in  a  great  majority  of 


sometime 


'tig-standing  cases  hard 


'  •">  of  these 


s  cietaccous  iiodiiji 


ii'in. 


I  inking  its  origin  in  tl 


instances    is   a    tiilierciiloiis  bronel 


;ii"l 


siilis<M|iient  peribronchial   alveolit 


ic  smaller  bronchioles,  leadiii"-  t 


finniary 
lo-pneumonia, 


Symptoms,— The  general 


IS. 


0  peribronchial  iiodiil 


es 


I  iiildsis  ill  the  child  is  s 
Mills,  li(iwev<'r.  as  miiflit  I 

allv  nil 


symptomatology  of  dn 


■onic  piilnionarv  tuber- 


Hc  abrupt,  and  the  first 


;","""  ""^'■""••' '"il^totl.atof  ti.ea.lult,! 

•e  expected,  certaiti  peculiarities.     Tl 


;H  tlic  iipe.x. 
tiilic'iriiloiis 


lie  c 


hild 


stock. 


miiy  have  I 


lymptoiiis  may  be  tl 


lose  o 


)Ut  pre- 
le  onset  is  gener- 


or  fhci 


'ecu  in  failing  healtl 


f  a  bromho-piieui 


noma 


ere  ma\   lia 


I  "iraHdiially  failing  heahli.  with 
suspicion  of  maliiria,  but  tlii 
follow  a   protracted 


ve   been    local    .rlandiil 


.or  come  of  a  markedly 


.•epeated  attacks  of  chills  audi 


If  or  bone  disease 


>»mc  case, 

'•'litis. 


mode  of  onset  is  not  so  1 


rogressive  failure  in   heal 
liistsviMpioms  to  attract  attention. 
ixtrenic  .iiiorexia  which  we  find 

"idi 

viiriiitjdiis.  persists.      Jt 

iK'distril 


liiso-pharvngeal   catarrh 


ever,  may  arouse 
i'e(|iient  as  iil  adults. 


witl 


III  find  strength,  coiiuli  and  f 


I  recurring  bron- 


lieie 


is  1 


ever,  are  the 


OSS  of  appetite,  but   rarely  tl 


■rsiil'.iects.     (Jough  is  ra!-..Iv  absent 


in  some   cases  of  pulmonary  tuberciil 


among  the  init 


short  and  dry  at  first,  siil 


lie 

osis  in 

lal  sviiiiitonis.  and,  with 


'iifcd  eiiually  throughout  the  <i 


•xysiiis  of  coughing  may  ret 


iikon  at  first  for  wl 


uru  at  fixed  1 


ly  or  IS  most  tronbl 


ibseiiiiently  looser.      It 


lOO 


Hull. 


Iiillg-coiigli  ;    l,|;t  tl 


lours,  so  that  tl 


'Xpectoiation  is  absent  in 


lere  is  never  the  noisy  ciowii 


may 
esome  at  night,  anil 
le  case  may  be  mis- 


ii,i;i'"t  ten  can  often  b,-  tauL'ht  t 


very  young  child 


rcn. 


CI 


ig  iiispira- 


«illi''ravisli-ye 


efit 


low  strc 


ik> 


o  expectorate 


Th 


.'tnires  uKin 

'•''il'l''<'n  inHh.r  ten.  "  Oertainlv'it 


onict lilies  it  is  more  .set 


■e  (Ictinitc'y  purulent.      Iliemoi.tv 

It.    ..1.    «^ /I         .       •       t         .        .  '      I 


SIS  may  be  said  t* 


iildren  aljovc  the 
sputum  is  mucoid  at  first, 
■o-niiicoid,  and  in  the  later 


Tl 


111  aiiKiiiMt. 


'"■I'll.  i-iMilis  from  the  i 
''I'liii'li  (if  the  pull 

lil'VUiil 


K'  terminal  luemoptysis.  rom 


IS  very  rare  at  the  onset,      h  i 


'e  infr<'i|uent  in 


iiptiire  of 


"ii'ii  in  the  adult,  but 


arv  artery. 


an  aneinism  in  a  small  cavity 


s  usiially  small 
'•are  in  chil- 


1"^  leiiiittent,  the  dail 


cniiiif 


l>  COllllllllll.  Sill 


y  excursions  sli;.dit 


ever  of  on.set  and  duriiifr  t 


tr  erosion  of  a 


le  eai 


•ly 


HIS  t: 


>se(|ueiitlv,  when  the  d 


■a  range   between    l()-_>°  atid 


■n  jilace  with  the  foi 


mation  of  cavities,  th 


isease  is  more  extensiye  and  ,soft- 


e  temperature  is  more 


\k 


W '  A\ 


II  ii 


i    ■ 


120    AMt:iil<AX  TKXT.liOOK  OF  I>JSI:ASI:s  of  <'Ull.l)lii:.\ 


NT 


h('(!ti(;  in  cliunicttT.  iml  thr  inoiniri;;  oltscrviition  mav  be  rioriiiiil  or  sulm  iriiilil 
wliil(«  ill  tlic  (.vfir  _'  tlif  llHMinoiiictcr  iii;i\  i.'i;isto'r  10;J.r)°  or  104°,  ,,i  ,.v,.,|' 
lii;;lu'r.  Chills  aiv  ii-it  ■•  .tv  (■0111111011.  lirfiidiiiij,'  sweats  aiv  fVo(|iicri'.  i,,,!. 
ticulail.v  towanl  tlic  ciosi..  Dyspiid'a  limy  he  j.roHeiit  at  tlic  onset  and  mni,.- 
thf  ciirly  sta;H('s,  and  mav  li.'  .Inc  in  part  rli  ilic  Ci-vtM-.  soiiicliiiH's  to  the  |,i.w,.|i," 
of  a  (lift'uso  Itronclims.  Markcil  incivasc  in  the  ivspirations.  wilii  cMumsix 
inilicatcs  very  rapi.l  projiri'ss  in  tlitMJiscaso.  In  protracted  cnHos,  just  n  u,  ||„'. 
iiiiiilt.  tlicir  niay  Ix-  very  extensive  (|cstnicti..n  <A'  llie  liinir  witlioiit  the  >li.'iii,.st 
(lyspnu'a.  The  ehihl  may  eoin|ilain  of  pains  in  the  ehesl.  iisiially  a- Mi.it,,! 
\viih  pleurisy.  In  a  majority  of  instaiiees  the  di.sea.se  is  painless' tliini|.-li„i,t 
Its  eoiirse.  Qvislinir  ,|i,ti..s  that  an  early  si^rn  is  tenderness  on  peicii~.|Mi,  „t 
the  aileeled  side,  or  on  pre.ssiiro  in  the' inteirostal  spaees,  piirtieiiliiii\  n,  (j,,, 
lii'st    spaee   at    the   apex. 

I'ro^'rcssive  weakness  and  wasim^'  are  very  pronomieed  sviiipt.iiii^  ,i„,| 
there  is  usually  pro;rressive  pallor.  Kre(|iiently*the  ahdoininal  viscera  h.rdii;.. 
involved,  and  there  is  diarrlnea  due  to  iMherniloiis  ulceration,  and  ili,.  Ij^.i 
and  splei'ii  may  heeonie  enlar<;eil.  The  urine  does  not  often  show  chan-e,.  I,iit 
as  the  disease  proLfresses  aliiiimin  is  common  and  a  secondary  nephruis  niuv 
develop.      A  child   may  (!onie  under  oliservatioii   with   ^fcneral   aiiasnic;!.  ,|i|',, 

partly  to  the  anifinia.  partly  to  the  renal  condition,  and  the  puli arv  iiil,cmi. 

losis  may  he  entirely  overlooked. 

Physical  Signs. — /iisiin-tioii  freiiuently  shows  in  advaneeii  cusms  un 
extremely  thin  chest,  with  marked  interco.stal  spaces.  Deforniitics  due  i„ 
moiith-hreathiiii,' or  to  rick<'ts  are  not  uncommon.  On  the  atVecteil  >ii|,.  tlic 
respiratory  mov.'ment  may  he  decidedly  less  marked,  or  the  clavicle  may  st;iii.| 
out  |)r(uuinently  ;  .u-  tliere  may  he  subclavicular  dejiression  at  the  aflectcd  li|i,.\_ 
a  siirn  usually  of  a  chronic  process.  In  verv  lon;,'-staiidini,'  cases  wiih  i,iii,l, 
lihroid  ehaniie  there  may  he  llattenin^'  of  tJie  atfected  side,  with  d.^prcxMni, 
of   the  shoulder. 

By  i)<ili>,(tl„ti  one  appreciates  any  ditferences  in  e.vpansion  on  the  luosiil 
and  the  iliflerences  in  the  tactile  fremitus,  and  it  may  he  of  valii.'  mi  (jifiiiii' 
painhil  points. 

PcrriiHuioii. — In  the  early  condition,  when  the  tubercles  ares':!t|.  cdortlie 
areas  of  hroncho-piieumoiiia  are  limited,  there  may  he  no  (dian;,v  :,.  the  m- 
eussion  note.  Indeed,  the  emphysema  about  the  aftected  areas  may  cause .s|i4t 
hyper-resonance  over  the  pari  affected.  Hxteihsive  involvement  at  one  un^ 
usually  ^rives  loss  of  resonance  beneath  the  clavicle,  which  may  amount  to  diil- 
iie.ss  and  is  accompanied  with  marked  increase  in  the  resistance.  \\)A\\w 
llatne,s.s  is  rarely  met  with.  Skoda's  resonance,  the  flat  tvmpanv.  is  not  fi,. 
•  liient.  The  cracked-pot  .sound  has  very  little  value  in  children.  ,is  it  iiiiiv 
.sometimes   b(>  elicited  in  a   thin-walhMl   healthv  subject. 

Auxrnltation  may  give  only  the  si;:ns  (d"  bronchial  catarrh,  pipiiiL'  nili* 
and  moist  sounds,  but  when  there  is  definite  diilness  there  is  iisuallv  clKUL'f 
in  the  character  of  the  rcsiiiratory  sounds,  wliicdi  have  lost  their  vesidilin' ciiii- 
racter  and  are  harsh,  broncho-vesicular,  or  (hdinitely  bnuudiial.  ^niiu'iiinrs 
with  defective  resonance  there  is  enfeebleiiieiit  of  "the  respiratoiv  niMniiur, 
with  prolongation  of  expiration.  The  auscultatory  phenomena  arc'.dieii  vm 
deceptive.  Diffuse  liroiichit.is  may  lead  us  to  suppose  that  there  is  mieli  trreiitcr 
involvement  of  the  lun,;:  than  in  reality  exists.  In  very  younji  infaius  >r^'nsnt' 
cavity  are  rar(dy  present.  I.iit  in  older" children  in  adviuiced  ciises.  uithliectic 
and  emaciation,  the  nietallie  .splashino;  or  amphori.  (|UaIiiv  of  ihe  i.iies.  with 
the  loud  cavernmis  breath-sounds.  leave  no  (bmbt  as  to'thc  exi  Kiicc  of ,1 
vomica.     In  cliildren.  more  fre(iiiently  than  in  atlults,  we  arc  deceived  by  the 


or  Hul.i,  ,riii|,|^ 
l"!",  (II  «.v(.|| 
tViM|U('ti',  |,ar. 

Ht't  iuhI  MIIIIIi^- 
t"  tllO  |il.>('||(> 

Willi  cviiriosi,, 
jii''t  a    111  tlif 

lit   lIlC  .-ll^'illist 

ally  a>-Mi'ii||,,,| 

(MX     tlir..||;r|,„i|, 
pcrcil«.|n||  ,,(■ 

iciiliirlv  ill  rlic 

i'iii]itiiiii>.  aijij 
■isci'i'ti  liccoiiii. 
ami  the  livci 
\  cliaiip',*,  I, lit 
lu'plirilis  uiiiy 
aiiii<ari';i.  i|i|,. 
(iiarv  tiili(.|ri|. 

t'<'ii  ciiscs  ail 
mi  lies  illif  |„ 
'<'ti'il  side  tile 
ell'  may  stiiml 
H'ectcil  jipcx— 
I'S  Willi   iiiiirli 

til  l|('|»l'(',\>lnl| 
tllC    l\MI  sillo, 

I''   'M  clicitiii.' 


'/YVy/vV.-rrAOAV.V. 


i)ii 


>.i-cailo(l  I»."«'ii(l().ciiveriiiiii-<  .si^ns      Oi 

or  of  l-Hitiv..  .lul,K..,s  insi.i'n.li,;,;  an,  !';!Ii'' "''I  "''''''>'"l>'  •'^•'••-'Hvo  re,Ho,.a„ce 

lnar..l..ras..s,vi,|,  Ih.|.  H.v  t  on  •        .   ,      ^  ''f  convoyed   M..,.ns..|v  tu  ,|„.  ..C. 

^'^c:u^'iT.:?fi'''-''r'r ''^  - '•  ■-' "'--;;;:' '-'  -  "'•-  ^'« •« 

The  Jis,.as..  is  ,.,„.kH,  n..w  I /Kv        ^i;  IV'' ''' ^'^  ""-■von.lm.hs. 

l:'™l'"Hin.nstm,t.,.nal  -.n,liti,.n:>o;,i..,i„us  ':„  \>'  "p/'^tm,,  .r  ,ho 
'"'^■'•'"'•'■••"f  ">^'..k,s  sinnilat..  ..|,>.c.lv  1  ,•  t,  „  '  "'■","'""•.•  ^  ""'  "'"  ''-■«« 
i«'inva«i„n  „f  ..Hut  ,,o,,i,;,„  of  ,|„    I,,,,!;       "  '■'"''  "'^'J  F"'"'     >   ir...n.te 

*'''''''i^^''i'lfcs'pi;u.niiil  u^^^^^^  i;!n'r'"^'  i-'^'-'-^-^  '■^'•■nsiv,.  (ii....,i,i 

""t'i""'.'.^  then,  is  ,|„|n,.s.s  at   ,1  .  1  ^  .  .       '  .""•""'  i'l"l"Ms.     Tsnallv  in  s,,.  I, 
•iv-n,oi,ssi^nsattl„.,„„.x       \ V L      nv         '     i  "."''.  ' ""^■''  '«'-'an..,.,  i,,,,! 

""■ ';!^''  interspace;.     A  eliil^   ml,;;'':""  ''"''^"^^"'  '■"'"  "'"  ^^'o.-n.!  ,o 
.""I  «"•  .V"«T.s  live  a   t„|,.,..,Mv  .•.  n  f;7  ,'  W-  ^■^'''''  /I  '"""  '"^■"■^"'•''  "f  I'-altl. 

..?rpr';^'':;;;;-;:'-';:-^^^  , 

>-a;.'s  tl„:  e,>n,li,i.,n  is  nsm.llv  tl.H?   „  'i;'^,  tubereulosis.     In  the  early 

I'll  "ml  repeatcl  plivsiral  exa'min-  ti  m     ,*","'"'"  '"•"•"•''»-pm..,n.onia.      ( ■„,.- 

^-'-'"•^^...s.  Tl.e  p. Ji,  ,  ,,•  t  r  'T''''"'  ^''^'""^  "'••  -.."1-tionot  fc, 
f  1-  1-,.  tho  in:...ease.    ^,  ^^.  oI  e"  ,?r  "'  '\"  "'"^  ?•' ^•'■""•"'  1-^-" 

rr'  ''•"'l'"'"">-  •■""ti...mle,l  i  om,  ■  , ,  r  /'  ''  '*  ,  '''^'  ^''T'  ''''"'  •"•^"''•^e 
li'n.^'of  tlu.  intercostal  space  '  ,.  tk  1,  i  ^'';  'l'"^ '■''''<■  •'"'"o.ss,  tl.o 
poii,t.s.  '    ''"'  •'""  "'^'  -'l'.-t'"ce  of    t.euiitus  are  valuable 

Au.sciiltiition  is  an  evt».f.i.i<.l,.  r.n     • 
•!"■  Praditioner  astray.     Wlu.n  in  loh/Zlv  liZ.'" '"■"'"••  ?5  ^''*^  ''"^«  '•"><  led 


""■  practitioner  astray.     W lu.    in        h/,?''''"'';''-^'  """■"'»••  "^  ^lie  l.ase  h„s  led 
> «-l  tW  the  purpose  of  ,Iia,n      .     T  e     it^;;!  li '?'7  f"""^'  ^'""'''  ''«  *'-' V 
1"'"";-'"^'  -metinios  .ivc^  a  .reat     >■    o  '  r  '  "*  ^'  '•■'""*^^  .^imple  l.ronel,,;. 

^ ■:l^''^''-'-  wlu.the,- we  l.ave  t    , lo  :   ;    .  '  ^.^  ''•■'  "/"^  ^''^'  '''"^"  ^'''■"'"'t  alone 


^'-i.eii„in..  wiu.ther;:  1.;  .^' ;  ,:r:  ,r;';;;f  •■'  r' ''"  "'"^  ^•'■"-'^  "'- 

InMlie  v..|y  instances  in  which  -.nv  f  *''l'^f  •"'"••^^  process  or  not.    These 

'"^'•'t  *•-  an,I  oxanune,l\,''    ;/;;•;:'  ;;;'"^  «*  ■'^P.m.n,  sliouhl  he  carefully 

l"I"M, tlifi.loffood  an.lwit.ll        '^^        ^  cou-hm^r  the  chihl  n.av  h.-in- 

|i""^  -t  an.i  exa„.;;.;;rlw';i;i.:^:'  ;;s;r"'""'  ^^'"^''  «''«"'^'  ^^  -••^'i^^ 

, ""■  ""'•■'■  ''■■""I.  .hen  case   a   : .    n  e   'l    -"  fT-'r'^'r  "*'  ^•»^'  '""^'-     On 
;-77,-|v  take  place.     Th,:  la  '^      Xj^^  .""f --'•^'''e  comlitio." 

**  / ;;:  :ri™;^a^^^^^^^^^^ 


»  ■  I 


If  t 


122    AMIUtJVAN  TEXT-BOOK  OF  DISEASES  OF  ClIILDRK.  . 

of  ,six  and  fiftocn.  f..r  the  reason,   no  doubt,  that  tlio  tubercuh)iis  I,,,,,,,),. 
l)iKMnn.)nia  is  so  otu-n  an  acuto  procoss,  carryin^r  oft'  tlie  victim  bofor.   it  1,.,^ 
assumed  the  characters  of  a  ciironic  affection. 

(4)    TUBEUCULOSIS    OK   TIIK    PlkURA. 

This  is  usually  secondary  to  existing'  disease  in  the  lun^  or  in  the  hi„i,.],i  i 
glands.     A  certain  number  of  acute  seroHbrinous  jileurisies  in  chil(h,i,  ,   ', 
be   as  in  the  adult,  due  to  tuberculosis:   but  the  cases,  as  a  rule,  rim  ,  f,v"; 
able  course,  and  unless  the  child  has  dehnite  manifestations  of  tubercui„.H  ^„ 
other  parts  the  assumption   in  any  given  case  is  of  course  purelv  "mitrtm 
1  iirulent  pleurisies  in  children  are  most  commonlv  associated  with  Inh'ip  ',! 
broncho-imcuiiioina.  but  in  a  certain  prop,.rti.u.  of  tile  cases  the  process  i.  t'l,!,,',' 
culous.      Ihe  (isease  is  usually  latent,  an.l  failing  health,  pallor,  and  sl,„iti„." 
ot  hreath  are  the  symptoms  for  which  relief  is  souirht.      The  <reMeral  s\  „„„„,„ 
atology  and  .liagnosis  of  tuberculous  pleurisy  are  practically  tlmse  of  \W  L.i. 
forms  which  are  elsewhere  considered.  -  ' 

(;"))  TrnKKcci.ofs  J'kkicakihtis. 

This   is  by  no  means  rare  in  children,  and  eases  liave  been  rchoit,..!  ,„ 
inhints  under  a  year.      In  (Jo  cases  collected  from  the  literature  bv  I!'„k„,,„ 
1.    were  m   children.      The  disease  is  associated  in  almost  all  instance  ui,!,' 
tuberculoMs  of  th..  mediastinal  or  bronchial  glands.     A.i  enlarged  an.l  soft  J 
gland  may  perh)rate  the  pericardium  and  produce  an  acute  sero-fibriiioii.  nr 
siippurative  infiammation :  and  no  doubt  a  considerable  number  of  ail  lii.uv 
o|  so-c.alle.l   idiopathic   suppurative  i)ericar  litis  have  been  due  to  tiiis  nnr 
llie  tuberculous  process  may  slowly  invade  the  pericardium  from  the  !,i,,li,, 
tma     glands,  and   produce  a  chronic   adhesive  pericarditis,  leadin-  tn  .,,',, 
thickening  ot   the  membranes  and   gradual  hvpertroi)liy  of  the  lirari    '"'ni,. 
patient  may  die  with  all   the  symptoms  of  ca"rdiae  dropsy. 

(H)    T^UO-GENITAL  TUBERCULOSIS. 

(.0  Tri!i^Kct-r.osis  or  ti...;  Kh.xkys.-As  part  of  a  <reneral  diffuse  tuber- 1 

in  .did      ''V''^''!!'  '/r  '"• '  ''■^■'^"^■"^•^^,  affected-more  commonlv,  indeed.  ,],:,„  ' 
adults.      Lsua  ly  there  are  scattered  gray  tubercles  or  coarse' vellou  ,„„h.l..< 
m  tie  cortical  substance.      Sometimes,  however,  the  lesion  is  primarv  .,„!  or,.  I 
or  other  kidney  is  extensively  .liseased.      The  aff'-.tion  in  these  ca.M^  ,„  ,'' 
to  begin  m  the  papilhe  and  calicos,  gradually  invades  the  substanc.  „,  h.uv 
ulti  nately  destroy  the  entire  organ,  conve-i„.  it  i„to  a  series  of  cx,avat 
c^mtauiMig  a  .  un^sy  material.      When  coiinned  to  one  ki.lnev.  this  (kMowl!   < 

et  thy  and  greatly  enlarged.     W  h.n    there    is   extensive    tubercMln,,;  nvcl' 

eplir,  ,s  there  IS  often    pain  over  the   kidney;   the  urine  contain.  |,„s  Vm 

'•,,';":'•    .''•'•^■|^"''"-  *!'^-^''- ■'■"1  '■'"lis  are  common.      Fre,,ucn,   inlruri,,.,, 

ma.v    lead   to  the  diagnosis  of  .ysius.   with  which,   of  course,  i,  j.  IVemumlv 

.ss..ciated;   but  it  is  to  be  b.,rne  in  mind  that  in  connection  with  ei.l,,. rah- 

k.us  or  tuberculous  ,,ye  itis  ir..,|uent   mictn  ;tion   mav  be  a  mark,.l  m, ,„. 

Nmietimes  the    tubercu  ous  o-vian  is  large  enoujrh  in  a  child  to  I.,.  ,d  dJ.-. 
luberculosis  rarely  produces  so  exte.isive  pyonephrosis  as  that  .hie  i„  si,!,,,. 

llH.  diagnosis  .-an  nnviv  be  made  fVom  ealcuh.us  pyelo-nephrin^  .xcopt  Iv 
tne  detection  ot  bacilli  111  the  urine.  i     . 


Hi 


irLDRI'L  . 

rculous  !k.„|,>1,c. 
im  befor*   it  I,;,, 


TVIiERCVLOSLS. 


in  tlie  liiMiirlii,] 
in  cliiidi,  II  11,,^. 
iile,  run  ,i  tinni'. 
:'  tubei'oiiiiisis  in 
ii-ely  ,i:r;i!iiitiiiiv. 

ll     with     |ul|;||.   ,,. 

process  i .  tulicr. 
r.  and  slmnni.^^ 
'iicnil  s\  iiijitiiiii- 
Kseoftlif  siiiihli. 


■on  rc|i(iri|.il  m 

'   by    I>";irkl||;i||, 

instiiiiccs  witii 
ed  and  sotU'iic.! 
L'r(i-fil)riii(iii>  ,,!■ 
of  all  the  ca,,.. 
(  to  tills  caiivc, 
:)ni  the  iiicilia,.. 
adinif  in  i.riv;it 
10  hriirt.   'Tin. 


]  2;j 

'I  ibemilosi.s  of  the  uretpi-s  ni„l  M    n 

,|i«ea  0  of  the  prostate.  ^^^^  "^  "'<^  kidney,  sometimes  to 

(/■I  TlMiKK('i:i,()sis  01,' T,,|.'  '|',-o.,.,^       ^\■ 
1--  in  ;l- testicles,  but  'x^Ll^s-'^Z^ f^"^' "^"^^^^  ^^  ^- 
"'■•!'  "'/•  "'•'■•en.     Uresehfeld  has  n.po  t    1     „       .  "'f-  "'■^""'^  '''^  "«^  "^  "" 

bsis  .the  testis.     Manv  <.ases  liave  C   J 1   '       1m  "*  ^""-•'"i^"'  tubercu- 
Iw  Julhen,  (   wore  undei-  one  vea  •  and  6  b  C  ''"'  r"'"'^'     *^^'  -'^  ^'"^^^ 

oivaii^  may  be  affected.     The'dis,.,',     .  '","'  '""'  *""  ^'•"■s-     I5oth 

allm^uiea  or  i„  the  opIdi.lvmL.  ,     le  /ir;;'""^'  ''"■^''"''^  '"  ^'^  ^-- 

ffll'<'l  tumors.     In  othei"  insfm.es      '  '"'  *'"'"'"t'"»  «'f  liard  oircnm- 

'!"•  ■' '-■  -sses  are  hu^e  ^  cSi       .Hr  "'l'^'  '^  T'''  '""''-•      ^V     n 

fr-  •"l-:^-nent  of  the'c.pididvmlr    '\  •  ^  ^'  "  ''"'"''■'':"  '"'  ''""'''^'  ^'""i"^^' 

™llyassonate<nvith  tuberculous  diJease  in  o.Lrml'r      xf"''-   '"  ^'''^'''■•■"' 

ai^ys  be  borne  in  mind,  as   i„  obscur    ..  f         ,    '^'^  *'-^i'^ti'i'«'o  should 

I—  of  nodular  masses  i,.     he  ^^   d,    i!^';;?'""'  "'i  f:""'  "^'^^^  ^''^ 

,  l''.^i"M  may  gradually  heal.     The  cb,  es    .  ''^'T  '"''''  '"  '''a^-'nosis.      The 

'^'"'l-  ''"'"i"^  adhesions  ,o  the  sk  ^{1  ^  on"  'i^^'^  ^''^""^  ''-^"  "'"'  suppurate, 

1.-.HC  inuch  cnlarged-the  con.M    on  L       K    l!      '■^""  ""'  ""  ^"•^"''  "'"y 

('■)  TlliKKCULOSrs  OK  THK   Fai       P     v  T   •  .?'  ''"  ^^''^"""'''^  orchitis.   ^ 

I  These  parts  are  mrely  aftecte.1  j^J  ;      , 'i,  "  ^,  fj  ''' '^^T'  ''''   ^'■'''^'H^^- 

I  -  "■  .enerali.ed  tuberculosis  lo  Hnd;'"  ^^ In'IS.ts.^:  ;Ubf;:;Sp- Ig^ 

IV.  Prophylaxis. 

While  the  possibility  of   iidi  i-it,.,!   *  •    • 

-^"-f  '•-  -'enied,  we  haye  to  face  ll  e  kcrt'l'T'''"'!  ^''""'  '"'  ''"^'''"^^^^l  '""ther 
;f  "';«:'<;'>losi.s  the  infection  is  at  th.\r,u!^]J;\"^';!^^^^^^ 

z'::^::^ :?:;:::::'  b-n.pi.-..andsi. -r^-t:::  i:^-;rtiz  ^: 
JJ  .n;rr^^^^^^^^^   s;S;:;r;;i::-^^^^^^^^  -V^  .-e.  care 

■"ii"''er.  Every  part  of  the  ex-n<.<.t  ,  '''''*  "^,\^P'"'"g  about  in  a  careless 
Wc;l.am]  the- Aiont-H  tidk  :  iS'    ;,,:  I't'    l'^  ^"'•^^""^   -"-t-'  and 

'"'''"'"'".vof  cliihlren  to  inf,rti..n     •,,  n  •"'"''"  '"'"  '^"'''"^  ^vater. 

'^"  "*  -'"'t^^  I-ossibly  on  acco  "  2^1^^!^  "w'^  ""•^i''  ^••^'^--  *'-' 
'm^  to  the  members  of  the  f.milv     .,  "'^'"■■'f^  relations  which  the  child 

'"'I'P™  f'>  '-liseased.       '  .e  1        t"  o  I^'"-^."'!!''"lv  the  mother  should     le 

K',i"?   -en-thing   in   th    "  mm  If^  ij  "f  ■"'""^\- '^'^ '••'-P  about,  of 
,,,„„„,^f„,,,  "  luoutlLs    mhances    greatly  the    liability  to  eon 

'.I  ™»z" ''"is;::,  h;,^;:::^!  i^,:;:;";-  ^^ ".  „«  ,„■ ,  „:„,  .,.,„^. 

ip;ind  .-alves  b<ro,M,.  infectel    vbe  ""■   '•'■'•Imess   with   whieh    young 

'■I'ave.  unfbrtunatcly.  no     •      ,;        Ji;  J'h  '  ",T''^  "^"  ^^'--.h.ns-eowlf 
."'■"'  -'--     Fortunalely.  ,ho  ]  ;  ,  t    ,     '       1      ''''""I  '''  ''"^  -'-q>tiMe 

'»'r:f",-e  ..careful  insj.ection  of  d  i  ^  ''"  ^^''  "l. '"^^  ^-'l^^'"-'  'o  the 

"'  '""'«"'  ""'l^-  '-.less  rhV  source  is     /  .     .    "  ,    '  •'"  ^"H"""-*'  'ie«  in  the  use 

r;:;::;;;;;.:"'''-'''---''' ^•'■--M::.;s>i^i;''y:;isss^ 

;^''fp:!"ti:;'tf!:^:;'v;:'^^^^^^  Achiidboru; 

"■"""' "■'fl"lH",W.atest  care.-    Very    .  cci  ''''i    ''fi  f^^-""^^''  should   bo 


iffi 


12A    AMJJIi/CAX  TEXT-BOOK  OF  DKEASES  OF  ('mLDI?E.\ 


;.'■  til,. 

ii'Mllli 


on  the  first  indcat.on  of  rnoiUh-breatl.infr  a  tl.orougl,  examination  of  tl, 
pharynx  shoul,  ho  nuulo  and  any  a.lenoi.l  vegetations  ren.ove.l ;  an.l 
tonsils  iire  at  ail  enlarged,  it  is  better  to  have  tlieni  cut  out.  The  ehild 
live  in  the  open  air  as  much  as  possible,  and  the  nurserv  should  be  thor 

ventdated    more  partieularly  at  night.      The  meals  shou'ld  be  at  regular ,, 

the  foo.l  plain  and  ni.triti.ms.     Every  eneouragement  should  be  gFven  „,  ,     , 
fats,  and  milk  and  cream  should  be  used  freelv.      It  is  a  -ood  nrncri,..  t 

the  mother  to  sponge  tlio  throat  and  neck  of  "the  chihl  night  and   , ,;;','; 

witli  cold  water.  '  "'r 

The  trilling  ailments  should  be  carefully  watched.     The  convalesce..,. fV,„„ 
measles    scarle     iever     diphtheria,    ami   whoopi-,,g-cough   should   be   >,„., 
guarded.     As  the  child  grows  o!,ler  a  systematic.li  v  n.gidated  ex.-rcise  .,1        ' 
ot  pulmonary  gymnastics  may  be  taken.  "^ 


V.  Treatment. 

Fortunately,  a  yerv   large  proportion  of  all  cases  of  tuberculosis  nr,y„ 

Many   instances  of    adenitis   and   disease   of  the   bones    heal    spont,. J' 

Even  in  pun.onary   tuberculosis   it   is  remarkable   how   often   we   fi  ' 

mortem  ^- n deuces  ot  heale.l  lesions,  the  percentage  in  some  series  l!,  ,„':  ' 
nigli  as  .iK  In  tact,  one  may  say  that  in  a  very  large  number  of  dl  ,:,  " 
in  which  the  bacilli  find  a,  lodgment  in  the  glands  ami  in  the  soli,|  ,  i': 
he  con.litions  not  being  favorable,  the  growth  remains  local  and  temls  ,  -  ,  | 
spontane..usly.  Ihe  essentud  point  in  the  treatment  of  tuberculosis  is  ,l„.  „ 
tenance  ot  nutrition  at  the  highest  possible  grade.  To  .li.l  in  this  tinv,.  ' 
ures  are  to  be  practised  :  '  "" 

First :   A  life  in  the  fresh  air  and  sunshine.     The  importance  of  ,,,vi,„„ 
ment  ,s  well  shown  in  Trudeau's  experiments  with  inocuhlted  rabbi,' 
confined  in   a  damp    dark   place  succumbed   rapi.llv  ;   those  allowci  t„  „ 
dd  recovered  or  showed  very  slight   lesions.       By  fin-  the   most   imp,,, 
ngle  element  in  the  treatmem  of  tuberculosis  of  all  forms  is  the  const.,,  i 
ation  o    fresh  a,r.    The  good  effects  obtained  at  (iobersdorf  Falkensteiu  S. 
Lake,  Davos,  and  Colorado  are  due  primarily  to  the  fac,  Hiat  the  p.,M.,„sl, 

hte  ,n  the  ojren  air  and  sunshine.     Even  in  cities  mud,  can  be  don.,  by  i„ 'i'  t" 
ing  upon  open  windows  night  and  day,  except,  of  course,  in  the  vorv  i,,'..!,.,,,,, 
jeasons.     It  is  an  easy  matter  to  protect  the  patient  from  drauglits,-an 
feve  1,  cough,  nor  night-sweats  contraindi-.to  in  anv  way  fresirair.     Tin 
reality  the  very  essence  of  the  climatic    ...atnient  of  tuberculosis:  ,|,      ,  |, 
considerations,  such  as  moisture,    barometric   pressure,   temp<.r,.t,„v  ,.„•     , 
secondary  ,s  wel   shown  by  the  fact  that  cases  of  various  tvpes  of  tide    ,1, 
rea,>.er  comp  etely  at  places  so  diametrically  opposite  as  Colorado  S,„i„.'     1 
lor  quay,      i  he  regions  of  high  altitudes  with  low  barometric  pressu,,.  m.o  m- 
tainlymore  stimulating,  and,  according  to  Jaccmul,  are  better  for  c-.^..  „f(.;,Hv 
pu  ..mnary  tu l.erc.losis.      Cases  of  bone  and  gland  tuberculosis  do  ,v,„,,,k,>l.lv 
ell  at  the  Adirondacks  and  in  Colorado.    The  level  irgions  with  low  l,,nvH„e„K. 
pressure   such  as   Riviera,  Florida,  and  Southern  California,  are  re,,,,,,.,!  ti  k 
more  se.lat.v,;  in  their  action  and  better  for  tuberculosis  in  th,.  in,.  ,■  ;„lv;„„v,l 
grades  and  with  high  fever. 

The  secon.l  important  nu-asure  is  feeding,  and  the  mitlook  in  mmv  rn,r.  ,,:„- 
ticularly  of  pulmonary  tuberculosis,  depends  very  much  upon  the  st„lnlitv,)f,lK. 
digestive  powers.  In  no  way  does  the  open-air  treatment  ,lo  luo.v  .-.„;,1  ,1,;,,, 
in  improving  the  appetite  an.l  dig(.stion.  A  highlv  nitrogenize.l  Ju  i.  consist- 
ing  ot  broths,  eggs,  milk,  and  meat,  should  be  taken,     la  child,, .  ilie  imlk 


Ibrillai'v  niedici 


tioii  of  til.  um. 
■'od;  and  ,r  tj,, 
lie  diild  ,ii;,||],| 
\  be  tlunvMi^'iilv 
t  re^idai-  iioius, 
e  given  1.,  UiU 
>od  pnici;,-,.  (;„. 
It  and    iiHii'iij,,,, 


'rUBKliVLLOSIS. 


125 


■0!ll 


valesceiK 

Id   lie   siHriiiln- 

Lercise  ni'  (•diiix. 


Kulnsis  recovor, 
•■^pontaiifoiivlv, 
we  find  [Mist- 
dories  Wwvf^  n, 
>er  of  all  rases 

f    Solilj    0|V;ll|s. 

d  tends  n,  li(.;,| 
sis  is  the  main. 
'li.s  tlircf  iii|.a>- 

:ce  of  enviniii- 
Ll)l>its.  TliiK(. 
llowcd  to  mil 
last  ini|Kimiit 
:'onstinit  inlial- 
istein,  SiuVHiac 
L'  [iiiiicnfs  live 
done  l)_v  iii>i.<t- 
'ery  incleincnt 
ts,  and  neitlicr 
!'■     This  ix  ill 

S  :  lli;lt  otiii'l' 
tlirr.  etc..  iiiv 
f  tidici'ciil'bis 
)  springs  anil 
'ssur.'  are  ccr- 
easi's  (if  early 
0  rciiiarkaljly 
.)\v  liaroiiiotrii' 
■e|iiili'il  til  lie 
iM'r  aihaiii'i'il 


iliet  is  particularly  to  bo  commen.le.l  vl.ile  fev.  .•         • 

vanoiis  meat  extracts,  and  peptone  1  j'"";''''''     ^''''  "'^ats  scraped 

I"  t.:^>ereulons  el.ildren  it  I  s.^::    ,:  'i^^^  ."S'  ^'  ^^^^^^  -  ^^^ 
ai.'i  '";iny  I^.tiont.s  ],avo  an  aversio     tn;i  '  '''*''"'^  ^  manage  tlio  diet 

>-t  ;|.lapted.     (lavage  can  rj;:! v       ,'0^.1";?.. •;;"'"  ^'.^""^  ^'-''  -^ 
llnr.l,   the   use  of  s„el,    remedies  as   co     ive       V"'^'  '''^^■"/'^"''g^'  i»  H'on,. 
»r;enK  winch  „np,ove  the  general  nn     tio„        ft V,  '    ''>l-l'l'«^pl'ites,    and 
nl.bing,  and  batl.,ng,  ail  of  wJuch  sti    ,  ItTand  """T'''-"'  '""■^  ^'•'''^^'""S- 

Liratment  directed  to  the  T,dun-  .„/         /, 

\  ti;-  «.,be..„iin  of  Koci^ t^id  t;  ;::fC:;;r'^---'''''''  ^^-^^  ^-^-nt 

f'  t»''"''t'l^'  baeiili,   has  been  nract   '    K   .         ^^^'T'"^'  •••^"■'^■t  of  the  culcui'es 

^f  ;"  ^'- i^-'ds  of  TrE     ,th;:r:;/''n'^''  ''^^  "-'•  -"'" 

n.i«;  IMC  hope  that  something  yet  may  h        '  ,  '  '""'''^    '"odification 

'^"''"••^"  ""■•''••''ti'>"  is  as  yet  nnknmY     'V'7'""r'''-^'H-<I   hy  its  „se.     Anti- 
^-I't..  agents  by  in].alation:^sui";M   "   ;,r     '  "  "'V-''-'^i""  of  various         . 

"lil-cai  tubereuiosi.s  is  of  ,.,-eat  interesi         1         '   ''"■*''-"^'  •''^•''""  *'''  iodoform 
•"I'^'i'^'i-losis  should  eneou>.rirl    m  r    wi  T'        ''^  '■'■'"••"■J^^'''l<'  ''flW-ts  in  jo  n 
«ase.     Creasote  is  a  remedy  i.  d  t  M^^St  T'  "  T''^"'  *'"''"^  "^^"^ 
tlic  tid-ereulous  processes.       h  nrol,.,!  l!  1  .  ^T'""  '''  ''™^'«cial  action  on 

i^"n,l.  it  is  statell  to  inHuenco  p     e  ;^^^;;:  "?  ''^'  '"^  -;ti'-.-iiian-  ac".;" 
«so  common  in  tuberculosis.^    1     e   ^s  tl     '?      '^'  ""^^  "^^"'^''^^^J  i-''^^: 
■'""  ","^-  ""P>';>ving  the  appetite,  .linun    ii  .'       '  f'  '"'  "'"^  ''  ^'^■"^''■"'  ""tritive 
'-'al'ol.sn.   and.  according \o  some/  s     '     i^;  '  !,/""^'''  "■'•V"-<.'»'«ti"g  ^'-o- 
^'■-'!,"-'-*'^Videly  used  than  any  ^tC       '  J^  rr^'       '\  '^  P'-"''"l^ly  at 
^""  yul.  some  practitioners  for  n>any  vL^t^  T''-      '  \  '"'■'  ^*^'^""  "^  *'' vo- 
te to  the  powerful    advocacv  of   ^;.'        V  "'^  I'l'mtroduction  bas  been 
l^f  ''^  given  in  h^r^^^^S  l^r^Z:'!^^',  ^•""••'""••''  ''-'  -'--      l" 
;'"'';'  ""■"■"  fl'^-e-  tin.es  a  day,  and  u  n^as^n    ;«  fiv""""^  '"  ^"""^  ^'''••''•"' 
nay  bo  given  m  /;«7,'.v,  or  in"  .ills  o,   i.         "  ''  "'"  ''"•■"  '*'"  '"i"i"'s.      it 

-iswithtinctu4<d-gentian.|£hd,        'S;"^r'"^^ 

Iv  the  laouth.     It  may  also  be  jriye,.    ;       '  r  ^'   /^';'  ••"'^'>  '^  ''^  ^ve!l  bornu 

^r-  ™.,/  consisting  of  crcI^H  '^.,  ^^.^'^  "    '"''i"''^'-'  .'1-  -cailei 
oiigrains,  water  to  one  ..unce-  a  te.sn,,,.  f  ^      ^■''»''j"iiate  of  magnesium 

'^" ^  -^''.this  are  stronglVv    .  m    ^         '  -  "j  l""t  of  wat<.r  at  140^    uC 

'"1-ti.^ns  of  n,,asote  in  oil  have  i-  e       n  H.,    '   T  •'•"  '"'  '""•''^'•-•''«'J 

?":"aool.  Iins  been  nn.ch  used,  both  by  tl       uu  l,.    I    "  "T''  ^'''"'^V^'  <>f  it, 

KhiIiUiom.  It  may  be  made  u,,  witi  '  ti  ut  '  J'vpo.lerniatically.    (ii,,,, 

■••-•        lv|.oderma,i,.ally.   il    i       .    Pw    h  '^^^^^^^T  ^'''''1^  ^'^'•"^'  "'"^ 

'.'""'•"•   '  "••-' per  cent,  iodoform  n,  .v    ,        ^^■"'^^/''l  "live  oil.   •,  j,,r  cent. 

'""^•''■•';  i>U.vted,  gradually  h  c      .  nf  ^  •> ''''''"^'"■•'  "'"'  '^'  '""'  ^  <-  of  the 

!-^  Y  f  "''^  ft--"  n-<-as.;te :   ,l"b   tfi    .,";  f '  u"  ''"''   ^  ''•■       <"-'  rareiy 

;""""•• ''■'■^''  airandag.r^l       e        f    ,":'   ^^'/r  "'" /'Hi-y   the   assodat    1 
;'  v-y  ,ie;u  service,  as  Witness!  1  i,.  0,  bm    v  T        "!   "''^''  "•^^^^«<'n-  i^  no 
hmkaliiv  tolerant  of  it    ..nd  <.  ,  " V'""''.^  '">'^l"tal  practice.      Patients  ,,.e 

"'-■'-.  such  as ^uJdvS,"  .  1;:^^ rd-;';, ■" -'r--  '''- '^'i-- 

'^'*''  ''wn  i-,.„mmended.*  '  "   ^•'"''""t'""^.   thy„,oI,  and  menthol 


I? '  'a 


:  Ulr;'-  .■.-:;-*,v.;^:i*ES;:r:£ 


t'll 


126    AMERICAN  TEXT-JiOOK  OF  DISEASES  OF  CHILDRE, 

The  cliiki  may  be  wrapped  up  and  taken  into  the  fresli  air  for  the  jrrear  >  p.., 
of  the  day.     We  have  no  thoroughly  satisfactory  medicinal  means  f?)r  n  ,1,,;.;',, 
the  temperature.     Antipyrine,  antifehrin,  and  acetanilide,  if  used  at  a'.   ^^J, 
be  given  with  groat  care.      Quii-ine  and  salicylic  acid  are  still  used  h   'ni„,v 
imictitioners.      When  the  temjierature  is  persistently  high  in  the  earlv  ^ti.-,' 
of  tuberculous  broncho-pneumonia,  cold  in  various  forms  will  probaMv  'ul't 
most  efficient  measure,  and  oy  careful  sponging  the  temi)erarure  may  be  n.,i,icJ 
several  degrees.      The  most  satisfactory  antipyretic  is  found  in  the  fresli  ■iii' 
more  particularly  the  change  to  a  res  M-t  such  as  the  Adirondack's  or  Cnl.in'l,,' 
In  the  chronic  pulmonary  tuberculosis  of  children,  when  the  fever  i,s  of .' 
hectic  type,  sweating  is  a  very  troublesome  and  disagreeable  symptom,  for  wlii,.!! 
atropine,  aromatic  suljjhuric  acid,  and  tincture  of  nux  vomica  may  be  iisetl    li 
young  children  great  care  should  be  taken  to  prevent  the  chillin"  of  llic  !„„i'' 
after  a  profuse  night-sweat.     For  the  cough,  if  troublesome  at  night,  \m^.ul 
or  sniall  doses  of  Dover's  powder  may  be  used.     Codeine  or,  in  extreme  ns,N 
small  doses  of  morphine  may  be  given.     Where  there  is  marked  ten<Ieni,.<  ■  ,„' 
the  chest  or  pleuritic  complications  the  cough  is  sometimes  relieved  l,v  miM 
counter-irritation  or  the  application  of  a  warm  poultio-e.     Inhalation  of  \mu\,, 
and  oil  of  eucalyptus  may  sometimes  diminish  the  profuse  expectoratidii. 

JIamx'ntysis  in  the  [julmonary  tuberculosis  of  young  children  is  usually  i 
terminal  and  fatal  symptom,   ([iiickly  beyond  treatment.  ' 

The  diarrlKiea  may  demand  very  careful  regulation  of  the  d'et,  and  if  m„ 
fuse  the  acetate  of  lead,  alone  or  with  opium,  may  be  used.  Preparatidn' (,|  ' 
tannin  and  gallic  acid  are  also  beneficial.  In  all  tuberculous  processes  tluMv:. 
a  more  or  less  marked  tendency  to  amcmia,  and  many  patients  improve  nuiiLK 
under  tlio  a.lministration  of  iron.  Careful  attention  should  ))e  oaiil  to  tli'. 
gastric  .symptoms,  if  the  digestion  is  poor,  dilute  hydrochloric  a'eid  mav  i,., 
used,  and  if  heartburn  and  pain  be  jji-esent  some  time  after  eatiiK',  iIk.  c;,',!... 
nate  of  sodium  or  the  alkaline  mineral  waters.  ° 


I! 


ILDliE. 


the  great  !■  p;, ., 

ins  for  rciiifii,,, 
isod  at  ii!i.  uC 

used  I) .  Mi.'iiiv 
the  oarlv  >x\vy^ 
probalilv  iif  '[\^^^ 
may  bon.,ii,(,,,l 
I  tlie  IVoh  .i||._ 
ks  or  (,'ni(,ni,ln! 
ho  fever  is  of  .,^ 
ptoiii,  f(,r  wiii,.], 
lay  he  u-cl.  1.,, 
ng  of  i|i(.  l„„],, 
light,  iMrc;;on,. 

extreinc  (>asi'<, 
i  tcn«h'riH's>  (,|; 
(lieveil  l,\-  ,iiil,| 
;ion  of  ici'oli,iii,, 
^toratioii. 
en  iw  usually  a 

'et,  and  if  ])ivi 
:*rej)arati(m.>i  of  | 
ocessi's  thci'i 
ipi'ovc  ([iiicklv 
be  paid  to  tii'o 
it'  ai'iil  may  !■.■ 

illg,   lllf  filHin.  I 


I 


C-A^X  V 


'( 


f!  ! 


DI8EA8E8  OF  THE  BLOOD. 


By  WILLIAM  (\SLER. 


ImnvODUC  TTON. 

The  blood  may  bo  lookod  upoi  .ili-r  as  a  fliiul  tissue  in  wliicli  thp 
corpuscles  rcpivsout  the  ct^lls  itud  ih'-.  plusnia  the  matrix,  or  as  an  iiitenml 
medium  bearing  the  same  relation  to  the  constituent  tissues  of  the  body  as  tlm 
external  medium  does  to  the  individu.rl  as  a  whole.  The  cor|)usdes  iiiiikiMi|i 
a  litti'  less  than  one-halt"  of  the  weight  of  the  blood,  the  rest  beinj;  |)lasiii;i. 
The  hitter  contains  in  solution  the  fibrin-forming  factors,  various  ])n)tci(l  >iiii. 
stances,  cMraetives,  gases,  and  salts.  In  healthy  persons  the  composition  of 
the  blood  varies  within  extreniely  narrow  limits,  so  well  compensated  arc  tin- 
"outgoings"  bv  the  "  incomings"  in  the  different  regions  of  the  bodv. 

During  the  \s:\A  half  century,  and  more  particularly  during  the  last  (Imitlc, 
much  has  been  added  to  our  knowledge  of  the  blood  and  its  functions,  nM 
of  the  advances  having  been  gained  through  improved  methods  of  iii-tdlniiical 
and  microscopical  technique. 

In  tlie  healthy  adtdt  hunuin  body  there  are  three  kinds  of  corpii.-clo  to  lie 
made  out:  (1)  the  red;  (2)  the  white;  and  (3)  the  so-called  blood-plaqims. 

The  red  blood-corpuscles  are  honH)geneous,  circular,  biconcave  di>l<s,  avor- 
aging  7.5  /i  (1  fi  0.001  millimetre)  in  diameter.  Tliey  are  non-nudratodrdl-, 
consisting  of  a  colorless  muuework  or  stroma  (discoplasma),  towiiidi  is  iiiiitiil 

in  a  })cculiar  way  the  red  coloring  matter,  luemoglobin  (paraplasnia),  tliiM i- 

bination  being  such  as  to  prevent  the  extraction  of  the  luemogi(il)in  hy  tk 
serinn,  in  which  it  is  easily  soluble,  and  at  the  same  time  protect  it  from  Ihiiliv 
processes  of  ox  illation. 

Tile  white  l)lood-corpuscles,  on  the  other  hand,  are  larger  ceils,  all  iiiiok- 
atcd.     There  arc  several  varieties  of  them    Mtfering  in  their  size,  ciiiitractilitv, 
miclear  form,  protoplasmic  granulation,  a-   :      -obably  in  function.  iiltl>oii}.'li   i 
this  latter  ])oint  we  areas  yet  profoundly  i^,.  :ant.     Some  of  them  arcGi]';'    "^ 
of  active  amteboid  movement,  which  may  be  watched  with  ease  in  tVreli  bl(i"l|;| 
specimens.     The  leucocyte^  will  be  classified  and  further  descri I xd  ulitn  » -■* 
speak  of  th(,'  differential  methods  of  staining  them. 

The  blood-plaques,  or  blood-plates,  of  Hizzozero  are  now  ginnalh  rcmL'' 
nized  as  normal  blood-elements.      They  have  been  described  imdt.'r  MmW 
names,  and  the  most  various  functions  have  been  assigned  to  ilnMi.    Tlw'^rf 
Hayem    regards    them  as    the    ordinary  red   corpuscles  in  an  tarlicr  .stai'i.j 
182 


hkI  ■  •  calls 
•  iii!a-!,iic  (lis 

'if 

\ii       I  ii.'e    iiilotlli 

liii'V  Stain  w( 
riaii-\' inlet. 

^raiiiilc-massc: 
'■i|iit.'i(i'>n  of  o' 
ilii'olv!'n-iip  V 

III'  '..'.r  iijodll   ((i 

injiciviiK'ed  in', 
:HV  \\\<-  led  or  ) 
ii"iiriiiiig  to  S 
liii«"l-|>lates  111 
liisTilied  bv  \( 
ilrir  liieiiioglol) 

ill  olivcrvatioii  ( 
'iic  ill  vest  |V;,f|V,| 

The  Orig-in  ( 

M-icw  < if  the  li 

limi-  of  over  OIK 

"iir  kiio\v|(><lov  , 

|i'i>Noiiilii'yoiiic  I 

W'^'  shall   briefly 

I>iiriii,ii;  the  fii 

'"imcd.     When 

«liii'li  ivrtaiii  soli 

v>>cls ;  the  ceiiti- 

I*'  liiciiioglobiii 

(•"I'piisclcs,     The 

iiinii  the  \'essel  w; 

•""'  "\'iil,  resenibi 

«"i'l<('l's   lielicvc   i, 

'ii  'lie  latter  eiiil) 

''""'''  ''"'iiple.v,  an 

■"'•"■■■'I.     Thewi 

'  'iver  inaiiii 

''    )>il>e(ichyina 
'"t<'f  iiivestijrat 
" i''-iimrrou)  also  { 
'"'liisions  nil  liis 

'  ''ill'  ill  man 
'■  "id  finally  tl 
■  ■  '  "I'litiplieati 

■'!''■"•  liS82,  So.  m.   ' 


in  wliich  the 
as  an  internal 
;Iic  body  as  tin; 
iisples  make  up 

bein>;  plasma. 
IS  ])n)(ci(l  sill). 
compositidii  ui 
'n.sati'd  arc  tiic 
0  body, 
tiio  last  (ii'cadi', 
fiuu'tioiis,  nin.t 

of  lii,-ti)l(ii;ical 

'oi'[)iisclc,<  t(i  Ix' 
KHl-plaquos. 
vc  dihks,  avor- 
•iiiK'li'atpdccIl-,  I 
iviiicli  is  iiiiitcil 
isina),  the  cuiii- 
ojrlobiii  by  the  I 
t  it  i'roiu  I'aiiltvl 

colls,  all  iiiiolc 
:c,  (■(iiitracfililv 
in,  altboujfh   lyy 
H'lii  arc  cap:'    'M 
'ill  t'rcsh  bill"!    ' 
rilicd  when  ^^■ 


/^Vr/,'0/;^Y'7'/0iV. 


■iiils    (lipiii  b.'HiiatobI 


if 


'fl;i-!.ii«'  (li> 


;isf> 


T) 


'-S  U'iurl,    ,„    fivsl,    |,|,„„| 


'<'y  arc  small, 
I. 


'■'ilMKJi,. 


11.    CO 


lorlc 


is; 


iro- 


[iaii-\i( 


I 


':-';';-''i'-'-.bioo.i-e<,.p„.,;i   ;;;■"•'  ;■;  i-^  ■■'■P-..n,  p,.,,L,„ 

'■^'"r" '  ''-tob..ist,  tbat  tl.,.so  b.I  "    ,      '  ""'      ^'";''^  -"  ••"-•iM.v  anv 

';'''fr  '""^^  ""^  f- -..nfbnmhH!  wi  b     '         '"^''  ;Pr<'"'-  gravity.     Tbo 

"-^  '--^''>''in.  J  ,,.sc.nb...l  tb;:;n  "',;:''"":?;  '•^''  ^'"''"''■^  ''"P'-ived  of 
:i"  observation  .o„Hnno(l  bv  P.i..o.,.ro  a  !•,"""''  "^'  "''''^•-^  tbn.n.bi-. 
•l-''-<.i,.ntio„s  ../•  Kb,,,,-,.  ancl^I    ;.;     I  """  "'"■■"•'.-'~t..a(,.d  bv 

The  Origin  of  the  Corpuse Ls  '  "'T'''  '■""'  ^''"'  ^'^  ^^  >■'"''• 

™'""^''"  ''^•-'-''-•'■nn  i^        ";;f  Jr'  '-■•'■•"■■.t  oxbansti.. 

-V"  "7'-  -'  ''"n.b..l  inustiX       tin  ■"  '■'■'■'•  ^•'  "' "^'•"•"- 

>'u-  k.umlclo,,  „f  t,,,,  ,,,.;.  ^  ,    '  f"'>  b..bi    ,t  ,„.,st  b,.a.bnilt,.,l   tbat 

""•™''"^-'-  H'i'    is    <.;.   now,  '    ;'^'-'--|:"-l-  citbo.-  in  .nbrvoni. 

'^-'-"  '>■-%  nu-ntion  be, v     .o    ,2    "T^r^''"^"'^  -">    "..-ttl.;i  sta,^' 

Tf-  '"*""  ^'"^-  ''^'  ''PP....  tb  •  r.y 7"  ='- ""  •''<-i-pus<.b.s 

"'""  '•'■'■^"■"  -li'I  -lunn,s  ar.  buM  dow         I       "r  '"'"  '"•-'•'"^•i"  <vlls,  .,f 
-f  =  H...  central  .dls  beoon,.  b.o  ~      ,  '1''"''''^  "■^''"  '''^-"•"  '''••-'- 

'*■  ''--^lobin  in  tb,.ir  porinuob-a        'i         "^''^  T'^  ^'•-'""'b'  -nn,u,- 

"™  ^''"  --'  -nils.      Tb^o  firs  ,   ';"'  7'";""^  -•<■  -'itri.n.ntiat<.l  to 

r  r'V"'"''^'^" '"  ='"  ^'"•'"'>'-t'^'  --ii    ' :  r^,  :•  ";'''•''"--•  Man.. 

'"'"■''  "'"'"-^••"'"'    P--i«<l  tbo  :    stt,  '  '^'"'"'■"'"•^  ''^  ^'-'^  ^t^'uo. 

7  "7'P'--'"<I    to   oxplain    it    t  0  •""'''"^""''"•'-^'■'  '->".- 

'  """  :     ''^'•" -•'^-  of  tbo  oaHv      ,r      •    ./''"■'^•■'''    ''"■•-■^  ''av.  boon 
"     '     '^'"■'  '"■'"'-":->''t-"-«.|  ,„..st  of't,,;     ,,,,•;  "'"^•"•^-  ™  "'•  tl..'  opinion 

'"^- '"-stigators  favoPod  the  d  "  t^.t  V  "'"•'  "'^"•■'-'  •"•'"'"-. 

"r":"''"'^^ '  "'^■'  ^""'^ ""  a  <>i..<Hi-  Id ! ;;  :;•  "^"'7i'-  ^-  ^'-^  ^i>''-"  -d 

'    •"«l  'inallv  tin.  I.,.„„„„..,.:  ,..         "^'  ^''^  '-"vnlatH.ir  |,1,„„,.  f,„ 


iindtinl 


'"'if'-niarnnv, 


plication  of  (I 


roj 


10  ro( 


>i'osfnt  siiocossiv 


Iivor,  tl 


10 


I  Hi 


weed  I II,, 


'<'f.  /', 


'/'•■«,  1882,  .Vo.  ;j()i 


'i"//((, 


/  .s;, 


'  «'»'lls.     Hoxvoll  snl 


f'<'oiitrosfo,.t|„,  f 


■"•''.hlx7\-  M,;/.Xavs,  I 


^stantiall 


ornia- 


.V  agroos  witb  tl 


lis. 


SS(j, 


Apl. 


('"itmlblatf  /  nwrl.  U 


if^.ini- 


/ 


184 


DISEASIJS   or    Till':    liLOOl). 


M. 


and  thinks  that  the  iicwly-forniiiitj;  vessels  all  over  tlie  Ijodvffive  rise  to  li|fii,(|. 
cells  by  a  softeiiiiiji' ot"  the  central  cells  ot"  thecolniuns — a  I'ael  which  ha-  Uitu 
proven  at  least  (lir  the  vessels  ol"  the  posterior  linih. 

'Pile  nneleate(l  corpuscles  i'ornicd  in  the  later  enihryonic  period  are  -malld' 
and  non-nncleated  forms  soon  appear,  so  that  hy  the  tit'th  month  in  the  Immaii 
tJctns  the  majority  of  red  cells  arc  non-nncleated.      At  hirth  there  are  vi  i  \  (;.^ 
nucleated   red  blood-corpuscles  present  in  the  l)Iuod,  and  they  soon  di-.i|i|ii;ii. 
ontii'ely.      In  the  adult  the  red  corpuscles  are  tbrined  almost  entirely  l'i..|ii  i],,. 
micleatcd  reil  cells  which  are  f'oinid  in  the  n.'d   marrow  of  bones,  di-i  ,i\-,.|.,,|| 
independ(-ntly  by  Xi'umann  and    l>i/zozero  in   l.S()>i,  and  since  tiieii  e;iivt'ii||v 
studied  by  many  prominent  histologists.       The  transformation  of  the>e  nmli. 
ated  colls  into  the  ordinary  red  jrlobules  probal)ly  takes  place  by  a  piMn-s  ,,(■ 
exti'usion  of  the  nucleus,  althontih  many  still  believe  that  the  nucleus  ui;ii|||;|||(. 
,'anisiies  within  the  cell.       The  lunuber  of  nucleated  ylobides  in  the  iiiaiTuw 
becomes  enormously  increased  where  there  have  been  great  losses  of  blodd^  im,] 
in  all  severe  auiemias  they  may  be  found  in  the  circulating  blood.     Thi'  im,!,.. 
ated  cells  may  divide  at  least  once  in  the  bone- marrow  by  a  karyokinciic  iiin- 
cess.      It  is  fronj  certain  light-bordered,  homogeneous,  colorless  ni.niciu-nll- 
(erytliroblasts)  that  these  true  lia3matoblasts  arise,  which,  as  I'  have  iHiintnl 
out,  arc  not  to  be  confused  with   leucocytes.       The  leucocytes  probahK  iievir 
change  into  red  globules,  although  that  idea  first  advanced  by  Wharton  Joins 
is  still   maintained  by  some  authors.     The  view  of  Ilayem,  that  the  red  ij|,i. 
bules    develop    from    the    blootl-pla(|UCs,  has    not    been    confirmed  hv  otjitt 
observers. 

xVs  to  the  origin  of  the  white  blood-eorpuscles  still  less  is  known,  A  dr- 
tain  numlier  come  frona  the  lymph-glands,  while  others  ap|)arentlv  have  tlirir 
birthplace  in  the  spleen  or  bone-marrow. 

In  a  most  interesting  series  of  articles  on  blood-formation  Luwii  ivi;;inl. 
the  lymph-glands,  spleen,  and  bone-marrow  as  blood-forming  organs,  iiml 
claims  that  in  each,  from  a  common  mother-cell,  two  kinds  of  cells  IVw  fidiii 
hicmoglobin  are  formed,  erytliroblasts  and  leukoblasts,  the  latter  haviiii;  uinu- 
boid  movement.  The  nucleus  of  the  leukoblasts  is  relatively  large,  ami  i  mi- 
tains  one  or  more  lumps  of  chromatin  connected  by  radiating  lines  with  iln' 
chromatin  nuclear  membrane.  The  erytliroblasts  are  never  anKrliuiil,  amlj 
have  no  true  nucleoli  ;  they  divide  through  mitosis,  the  leiikoblasi-  dividing 
through  amitosis  {'Vivmn  Indlreda  per  (/rdmdn).  His  erytliroblasts  ijo  nvir 
into  the  blood,  as  a  riiie,  free  from  luomoglobin.  They  gradually  nivnmiihiif 
coloring  matter  there,  and  so  become  nucleated  red  blood-corpuscles;  the  iiiicIhij 
in  the  main  becomes  disintegrated  and  gradually  disappears  by  al)S(ir|)tioii. 

An  exhaustive  review  of  the  difrei-eiit  theories  of  blood-format  inn,  toi;vtliif| 
with   the  results  of  his  own  experimental   work,  will   be  found  in  Ihmi 
article  in  the  JoHvmil  of  Mnr})linl(>f/i/  for  June,  1890.     Howell  inaiiitaiiis  tli;it! 
the  red   blood-cor))Uscles  in  extra-uterine  Hie  are  derived  iVotii  lln'  niiiliMltilj 
red  cells  (normoblasts)  by  a  process  of  nuclear  extrusion  (the  pioa-s  in  liia 
'  Centndblalt  f.  meil.  ]\'in.'<en.'<cltaj'teii,  1878. 


[arHlic  y,.;-ts  of  a 
fliai   they  st 

|i»«'ii>,-i(iiiit  iif;. , 

l^f*'!  upon  as  a  ; 

I'" 'Ih' cxiict  origin 

'"■ills  reached  an' 

[smlcd,  1111(1  wo  tnii 

^nintever  may  I 

bvc  boci  struck   i 

Wii'f?,  tli(>  norma 

»■  cirpiiscles  soni( 

•I'l't' of  thirty,  fo 

''''k'  ii/1'tiine  of  a 

«i>i(lcnil)|y.     The  I 

'■""I''  'ipiH'ar  to  J,a, 

'"'■''•  '■''  (I'll'',   wouh: 

'"''  ■'I-'  ^vc  are  al: 

■"'"Wl  from  tlic  1,1 

'"""Jl'  If  i^  impossil 

!':'^  "'■  •li^int<v>-atio. 

'"■''  'I"'  ivd  <'ells  ai', 

'  '"'"i-marr„,v  iaig, 


•  riso  to  lili,,,(|- 
liicli  lia-  iMt'ii 

k1  arc  -im;i||i.|. 

I  ill  till'  liiiiiiiiii 
ro  arc  vriy );.,( 
.soon  (li-,i|i|H;,r 
tiroly  I'lMiii  |]„, 

lies,  (li.-c.iVc|'|.(| 

tlicii  (■.■iivliillv 
ly  a  ]>i'iMr^>  i,t" 

■1CUS0|•;|,|||;||)^. 

II  tlic  iiiiirn.u 
s  of  l)lo(i(|,  iiml 

I.       The  llllcl,.. 

■yokiiiciic  |ii',,. 
!  iiiarcow-rcl!- 

IlilVC     iHlilltlll 

irolialiiy  iicvir 
Vlinrioii  .luiii> 
It  tlic  rnl  -In- 
iik.mI  1)v  (iilitr 


/^vy'A'o/>rr7'/o. 


""  '"  (lie  mar 


row), 


Willie  ill 


Ih: 


!'^""t"  t''<'  ..irci.la.ii.o.  |,|,.,„, 


ittia'iiii; 


1    S()I)|(, 


kiiii 


iiiid  I 


iiivdcrivod  (r 


lavc  tlicir 
"II  <'olorI 


lie 


""l'fll()|,|;,..jt^ 


IIIC 


'"■'«iii  in  .stijj  J 


eatei 


red 


''•■^■•^  mature  / 


arc  allowed  ( 
'■^  'lividc  l,v    I, 


>n-i 


""fotie  divisions  off  I 


^'■^•"^^  I'ntlM'ol.Iasts,  i|„.  I 


■'  '"•''^'\'«'s  (liat  iii„|, 
ii''  .«|ileeii   may  agai 
111!  eruditions  it  ^\y 


le  \vel|-|< 


itlcr 


er  cert, 


"""'11  man 


'"■'"•S  Wliieli    i„  ,1 
'"•viii^r  rcsiiJi,,!  / 


'•;•  pJKi.oiooi,,,)  ,,,„„, 


(i\v-cc. 


will 


'>  pass 
<arv()- 


'•'ir  fiini 
rom  siic- 


"".'"  "•^•^""'*'  'i^  red-cell  |,„iM 


''■■^  "I>  at  liird,.     'j^i 


Ih 


Illy  ( 


'  Vcsieiilj,,.  „|„.I 


reiiic  ;i 


lamiitt 


"■""'•  ^'1^'nionts  of  tl„.  hlood 


view  ad 


'«'  I'cgarded 


that 


NH'iiemir  retr()(rc(,, 


"'^'  ''<'velo|.ed   fn,i„  t| 


""■■*   with  e.vt 

'""*•"'"".  wJ.iel,  ,„„| 
a  need 


ei. 
iia'iiiia 


er  iiur- 


■■'  I"''y"ior|,|,oii.s  „„(,] 
'^'f  clianw'. 


'"•"^■•■".  l>"l  most  liistol, 


le  s 


''•^-  'J-'^^-'ll,  tliat  all 


oils    III    tl 


'I'  "rdiiiarv  j 


'^^'■■^ts  agree  wit|,  | 


mall  IvmnI 


mpli 


"•  ''■'<■'   tliat  the  nnel 


''""Jtytc  iiKJi 


oevtes. 


"Ill  ill  (hiiil< 


cat( 


•■'  a  eoin- 


ilNirhi'd  lias  heeii 


ens   „/•   tj„ 


iitk'iits  in 


•""•Pportcd  I 


"I'li'i.ir  definite 
IJiielly  suniini 


"ly  wards,  |„it 


>y  mi'iKiroiis  ol 


'lonnohlastf 


'■-\tnided    rather   || 


can  at  ni 


as  to  tl 


le   lilt 


«'"'-va(ioi,,s  „f  the  |,|„„, 


lan 


present   \> 


''"'f  't^iho  adnJt  the  i 


"^^  "P  onr  knowh.,! 


aid 


""ate  fate  ..f  tl 


ana'iiiii 


"•  <'\triided   ,„„.| 


ens 


«'<■  of  the  1 


lit  ill  tl\> 
liHur  iif  its  I 


";"<-"'am,w  n,„|unh,,,d| 


-"='^""'  "f  the  re<|  gl,,,,,.,,,. 


«^'"^'  a  dev  .J 


'J^li 


•I'l'fii  lias  always  ha 


Mil  we 


loo 


k   i 


»  i'<Wirded 


"l'""'"tal  centre  for  wl 


lU'iiiopoioti 

y  takes  t\ 
ere  i,s 


"rgaii... 


we  inav 


"■  """^f  ''"'p'^-tant 


pport  for  this  th 


•"■  ('""firmation  i 


'"*  a  blood-niak 


"fc  lilood-, 


•">  "iiieh   evid 


eiice  Ml 


<ing  opo- 


•''•I'juiseh 


laiv  tlie 


corv, 


'■"'"  ^'^^l-cn-inental  worl. 


Ill,  vet 


Tl 


le 


^ts  of 


a  eoiistant 


'^''t'  lymphatie  gland 


"■<■  'mist  admit 


"f  tliai    they  stand 


product 


'""  of  eolorl 


and  adenoid  t 


^ve  find  almost 


no 


:vcr  111 
«iko(l  I 
I"  the  exact 


-•Kliilt  life, I 


'"   -'"y  ''t'VelopMiental    irl' 


t-'«.s  corpuscles,  Init  t] 


issue  geiieralh 


"<'^  "ot  mannfiiet 


I'""  •'■^  "  •'^fat  of  blo,„l.,l 
'■"  «^"  tlie  formed 


lire 


hlood- 


'f"»"  fo  the  red  cell 


K're  is 


no 


oriL'', 


('•"^tniction.     \\ 


'••"'P"^L>Ies,  but 


niij;  ivaehei 


'lei 


inav 


Th 
"'"■•^t  rather  I 


mh 


riiat. 


and  we  must 


"'y  iiiianiniitv  of 


"^''>f«  «'<•  the  bloo.I 


lavc  be 

V(lill«r    tJi 


ver  may  be  tl 


"•ait  for  fnrti 


"I""'"".     Onlv  a  f 


ay,  therefore,  that 
we  are  still   fi,,.  f 


JO 

as 


I'om 


■»'»  struck   with   th 


^"  mode  of  blood. 


"''•  '"vestigatioi.s  to  c| 


•■"  points  are  definitely 


'«.  me  normal 


<'  i'<'"iarkabl 


'•('H'eiieratioi 


,  everv 


•''I''  "P  'lie  subject, 
must 


<'iimciaii 


pw  cor 


'puscles  sonieti 


Pi'oportion  of  red  1,],,^^, 


':/T"y  ^^i^''  "hich,  afh.r 


Hie  r 


■'tf  of  thirty,  f; 

Tk'  Iif;.      ■ 


me; 


)rt\-, 


''  ""<'<■'•  favorable  end 


f'"i'piiscles  niav  I 


""•'  "''  a  red  blood 


>i-even  fifty,  tl; 


onsatid  per 


""'lis,  beiiH 


Jirofiis 
«'  i-estored.  tl 


10 


111 


^"^'■'•''''y-  tih>  biic-coi. 


•«Jrpnsc|,>  ,ve  do  „ot 


'"m.  a  (lav, 


:"iufaetured  at 


roil  III 


•'PI"'"-  to  have  tl 


onng  niatter.- 


;i;  ,w 


and 


fiiK'li,  if  (ni(. 
'^"'  "^  wc  are  ab|. 


K'lr  origin   i 


<'<^i-tain  of  tl 


y  varies 


"■""'''   '•'>IJ    /or  thv  .lailv 


"  an   altered   1 


lii'inoi 


[PlMuVcd    f,., 
ri|(lli(r||    I'f    j 


o  see, 


'".  f'"'  '>lood   before  t! 
possible  as  vet  ( 


lowever,  the 


•le.striiction   of 


'f  probabi 
't'  "I'iiiary  pigments 
globin—a  eond 


Hion 


nianv 


re( 


'fy  'lave  under 


corpnseles   w] 


OOllIc; 


)bl 

'f'"   worn  out 


:':(''™'.«™«..n,H„:»;,;,,zri"'' -':■-'> 


"f  a'ly  marked  ci 


are 


"I'll  tlio  r 


'('(I    C( 


•s  are 


"'lif-iuarrow 


brol 

'ai-go  ceils 


P"'<'ii  and  liv 
veil  lip.     Oc-ea.. 


t'l-  are  beli->v(,d 


witJi 


laiige,. 


eaii  b 


lonall 


y  ill  tl 


to  bo  tJ 


i-e,!i:ard  to  the 


10  organs  ii 


^  «-t'"  fille,!  with  red 


"'  normal  sjijee,,,  | 


«»i-pti,sele,s  and  it  I 


iveiv 


i;is 


i; 


'II' 


18(5 


/> AS'/.. I, SAW  ()/'  ini:  HLuon. 


I)ci'ti  thniiulii  iliat  (hoc  ;iiv  .luod-.lc.siroving  vAU.  The  cliaiijj.vs  win,  ,  ,|„. 
ivil  (•(.i|iii,-clcs  iiiHlcr;;.)  in  tin  maiTow,  lis  v,  aiitl  spN^-ii  have  Im-cii  i-imhIIv 
.stiuliVd  In-  (Quincke  and    I'dciv,  wlio  hilVr  iSCCIi  tin;  inoiiicnl   stdivd  ii|>      ,|j,:„ 

tlic  cells  of  tlid.sc  ui'uaiis  in   ilic  Ton  i  of  an  aliiinninafi'  ..('  ii ,  ivail     |,|n|,. 

ill)ly   to  !)(•  n><(l  liver  again   in  the  'Irvclopniciil   <(f'  nt'W  (•(.r|Misi'l('.,. 

Blood-plasma. — Tlic    study   ol    the    blnod-piasnia    is    dailv   assuniinn 
grcatrr    ini|nirlanci',   mitwitlistamlliij;    the    icndcncy    to    attril)nlc    all    -en,,,,, 

l)l(i(>d-i'lianncs  ((I 'iinscnlar  altcratidii.-..      It  cuiitains  water,  a  r     .■      ,iiii,,ii,it 

of  sernni-albnniiii  and    set  iiMi-glolinlin,   willi    small    (jiMntities    of   innru,!,,,,, 
salts — .sodium,  i-aleinm,  potassium,  and  maiiiiesinm. 

Tlie  in  vest  ij-at  ions  recently  (•.•irried  on   in  connection  witii  the  (jne-iinn  „f 
inininnity   liave  lid  to  a   Uiiowled^'e  of  certain  pi'cvionsly  unsnspect,,!  pn,,,. 
orticsof  tlie  .senim.     (Jroluiian,  .\nttall,  IJelirino-,  Xissen,  I5nclni.r,  and  ,,t||,T. 
liave  proved  e.xperimeiitidly  that  the  fresh  hlood-.sernm  of  mammals  ha^  h,,u. 
crfnl  jierrnicidal  proi>erties.     This  l.aeterici.jal  power  of  the  serum  of  .lid'dvnf 
iuiimal-  vai'ies,  and,  what  is  still  more  interest iiij;',  the  mi.xiiijr  of  the  >.  inm  ,, 
one  animal   with  that  of  another  residts  in  the  destruction  of  the  Mviiiijri,!;,] 
powers  of  both.      What  the  substance  is  that  po.<sesses  these  peculiar  |Mucr.  i- 
is  ditlicult   to  say.      It  must  be  an  e.\eeedinjj;ly  unstal)l(>  Imi  ly,  since  it   i>  iv,,. 
dered  inactive  l)y  warminii  at  a  temperature  of  ')r^°  (  .  for  half  an    iniir,  i,,,,] 
exposure  to  liu'ht  also  robs  the  serum  of  its  irerm-killin<i  iuHuem    . 

I.andois  .some  time  a«ro  poiiit(>d  out  that  the  blood-serum  of  one  Miiiihil 
had  a  destructive  action  on  the  red  bjood-corpuscje.s  of  an  animal  of  a  ditf,,. 
out  species— a  fact  wlii.-h  explains  the  worse  than  usolo.s.s  practice  of  \^U;\. 
transfusion  from  lower  animals  to  man.  [iuchner  has  shown  that  thi-  ''ul, 
lieidal  "  action  of  the  .serum  is  quite  analouous  to  its  ird-mieidal  actii.ii.  N  ,[ 
only  are  the  red  blood-corpuscles  destroyed  by  the  t;)roijru  scrum,  l)m  \W-\n\. 
oocytes  are  killed,  as  shown  by  examination  (in  iho  war  i  sta<'c.  Iliicliinr 
further  refi-rs  the  antito.xic  action  of  the  i  :>  ..d-seruin  of  immune  animal- tn;i 
quite  analogous  chemical  action.  He  does  not  believe  that  the>c  -iihstiiim-, 
germicidal,  globulicidal,  and  antitoxic,  ('an  b"  i-iple  "dead"  protcids  in  s-H 
tion,  but  regards  them  as  highly  (•om|)lex  molecular  conihiiuttion-  wliiiji  m 
some  i)e<'uliar  way  are  (ie|)endcnt  .for  their  integrity  on  a  loose  .  nnibiimlinii 
with  salts  of  the  alkalies.  Hankin  terms  these  bodies  alexii  ■  an<l  l)cli.-K 
them  to  be  derived  from  the  leucoeytp.s,  particularly  .'  eosinopliile  viirid 
which  secrete  them  on   suitable    ])r()vocatiou. 

The  whole  (piestion  is  piutieularly  interesting  fr.  a  t.  ipcatic  <taiii 
l)oint,  and  at  present  "  bloi.d-seruni  therapy  "  (/.  c.  the  Mijection  of  llip  scriii 
of  inunun(>  individuals  into  others  as  a  protective  or  curative  meM.-iirc)  i>  Hl 
of  promise.  S<ime  astonishing  rcsrdts  by  this  method  in  ea.scs  of  trtaim-iiiv 
claimed  by  the  ftalian  school,  and  in  Herliii  experiments  are  bein-cMrncilim 
by  the  Klemperers  and  others  in  connection  with  pneumonia  and  the  su-i;iiy 
anti-pneuniotoxin 

Isotonia  and  Hyperisotonia  of  the  Blood-serum. — The  tenii  "isntonie 


solution  "  was  introduced  by  irainbiu'ger  in  1880.     It  is  well  known  that  I 


'i'"''  "■erk  in  the 

Examination 

ffiiii:  cleaned  as 

'i|'(tlici;.nnerl)ei 
'.TOltll(ireiiu-),Iv,|,,, 

I'll'' first  (Irup  ,„.  (\, 

'"■■''1  with  a  pair  o 

Ijf^^^ti.'i,'  drop.  car,. 

''"■  l''"i'iif.    .kin. 
W'"«l-(lro|)i,.(.     jj, 

'''  ii'i'liiu'(|ue  1,1 
»^-^'-  The  spec-in) 
"ll-lii'-iTsioi,  |,,„,^_ 
"otod,  th.-  relativ 
""^■'■'"•■'it  of  fhe  len 
alaWa,  spirilla  ( 

'"'"'"■■""•oof  certain 

"" -Ct)i-pi(; 

""^f''f''\-'-n.Ncd,„„ 
"■''"■  ^pwiincM  will  I 


(■  Im'cIi    .'     ,  iillv 
■tdivd  lip       ,.|,;^, 

> ,  n'lid;    |,|.,,|,. 

|nisc||.>. 

lily  iisMii!iii|H 

)utc   all    .,Ti„ii. 

.'Hiiiiiiiir 
cs    ol"   iiiMrMiii,,,, 

*ll<'  (|llr-l;,,||   ,,r 

i.siispcct,,!  j,|.,,|,. 
Iiiii'i',  iiiiil  otlicr, 

imilills   ||;|,  |,„„. 

I'imi  of  .|;ti',.|viit 

Ol'tjlc  >,T1||||  ,,t' 

'  tlic  pTinii'iiiJ 
■oiiliiir  |MUciM! 
,  since  it  is  ivi|. 
It'  an  .•Kill!',  iiml 
lie  . 

I  <>t"  line   Mlliliiil 

uial  (if  a  i|i!)ri. 
mtico  of  l)|(in,l, 

lat  tliis"g|, 

al  action.    \i; 
HI,  1)111   ;lii'  !,.!|. 
tagc.     r>;icliiiiT 
IK"  animal- til ;i 
lesc  -iilistniiiv., 
>r()tci(l<  in  sd'; 
liun^   uliirli  111 
'.so  ciiiiibiiKitiii 
and   i)clii'-!s 
!i>|)liilc  variiH' 


fy'/'iju/ff  <-/•/( 


>.v. 


i.s: 


^f  ";•>:''••'"."  '•'•  tin.  ,,„|  l.ioo,|-cor„„.,.|c    • 

'■'""••:""v<"lwiflMli.,iIlcd  water      U      "  "'"''■"■""'  ''•""'  "'<•  -»n,n,a  u  li 

■""".-'"" /"■•■vm  tin.  .solvent  aci   .    I  "''""""    ^^'"''•l'    is    in  f     , 

'"      '■''^  ""•  ••"llee.,tlV,(io„  „|    tl,,.  „,|,         ,  ''■  '^■•''^•■'•Nilll.l   oiImts 

"  '!"•  x'ni.n.      Uv"sav  '  *  '"  «''<'"t<T,  if  u„  ,„,,,^,  ■"?   '  '  """-•ve 

""";;''    -"Its   (o    ,„,.v,.„(    den.     .•  '    '"'  '""'   '"  Hide],   ,f  ''•'"•'• 

..liatcnane..  o/'  s, Ll.  "  ""•^"•"  <'f  tl.'  .•..r,n,seles   ,t       '  ""''"  •'"•^^ 

■""  "'  "",i'' "r» " '■'»■•"  "'■  tw.  ,..„„  ../„,„,,,■,;; 

;;-:.::ic;:;;;;;t;;,*rr,r/V'''""'-''' -' 

/*«i-:';.-n,mn.:,,i,,,,e,,i».;;;;;;,;Y;»|^^^^^^ 

;;■»">■"■  ».-ivof  .1,0 u.«.i,„„k, „!,.■,,'"  " '"" -'PI'.-.™.!,,,,  „r„-i„-,,, j„ 

'r;77^'■b•..;;;a'M^;;:;:;;;:;-;;;;■-»i..■.^.«^,:,:i::,;::;;:;-:; 

icoevtio  form«  ..,,.1  ;...,         .  '"'*^ '*"t  SOn)otime.< 


r'i>'-.!i,i„„,j.., 


iilKf 

k  tlic 


ic  c.xcivis 


"i7"i"<'l<'.s,  thev 


iiiav  (j( 


^I'et'iiiie 


tl  wi 


"Of  to  allow  ,!„>  „il-(l 


i,and  if  thorn  l,r  a  1; 
^et'ii  it,  f|,o  f,.(..sh 


'!> 


11  be  (] 


otitri 


>ywl. 


1-op  to  reach  the 


^J-gc-  'iiinihorof  niicl 
^pwinie,,.     Soni 


edge  of  th 


(  cai-e 


e  oover-gJas,s- 


il: 

Mi 


1K8 


i)/s/:.\st:s  or  riii:  //aoo/>. 


Enumeration  of  the  CorpuBcles. — Tn  n  liciiltliv  miin  flu'i'csliuiiM  Im  (Vom 
five  to  li\  ('  ami  ii  liall'  millinn-  of  n-d  coi'ihim'Ics  in  .1  cuhic  milliiiH'Irf  ni  IiI.khI 
tlic  number  in  women  Itcin^  iiDrrnally  it  lidlc  iiiidcr  tliis.      Tlie  wliiii  u1mih|. 
CDrpiisi'Ies  vnrv  in  niniilxT  at  tlill'crcnt  (itn-^  ol"  tlic  iluy  ;  tluis,  tiicy  an  m,,! 
numerous  after  a  meal  than  (liirini;  the  ilii^c-tive  prooess.     Speaking  gen,  i;il|\, 

Fid.  ;i. 


OJ 


O 


c 


ii. 


cs. 


o 

o 


l-i 


o<i 


a 


■3 


o 


^> 


o 


■a 


<;;> 


c 


.v-,0 


c 


^ 


Ci 


o 


D      C:i 


C 


-o- 


o 


i^ 


0 


^- 


0 


O 


::> 


0 


-Ta-< 


-^ 


O 


o 


C 


.21. 


0 


tJ 


o 


.^^ 


cO 


Ci^ 


o 


o 


O 


D 


A   ^^ 


Tliuiiiii-Zciss  HI I'CoiMitiim'  A|>|iiiratiis  tMiiilit'ck). 

A.  MelauL'i^iir:  a,  Ciipilliiry  tuhr  in  whicli  the  hi 1  is  tiikcii:  b.  ('Iminhcr  fur  inixiii'.'  Ilir  lil""'!  »;'| 

the  (lilutinK  solutiim ;  c,  (iliiss  hull  to  aid  in  niixiiij,'  tlic  bldiiii  with  tlii'  ililiitiiii;  snlmi.m. 

B.  Cross-stM'tioii  (if  the  chaiiihcr  in  wliiih  llie  hliiiid  is  edunteil. 

C.  Sectinii  iif  the  field  on  wliieh  tlir  IiIckhI  is  ciinnted,  shii«  inj;  thirty-six  S(iuares. 

D.  DiaKrum  of  llie  wlmle  liilil. 


tlionwrnjifr  i 

fn'O'lO.         'I 

ivil-known  ii 
III  till'  ''mixer 
•[lecilic  fjravif 
iw'oniiiiendiMl 
vliicii  tlw  wJi 
'  The  drop  of  tl 


"■'""  «ii'-biil)l)lo,s,  am 
WefoseeAWton's 

"'''  ''!•'  «»ri.l,.s,.I,>s    h; 

*  "'^"'it.    Two  ^vlu 


|lli:i|| 


squares  in  vac] 


llicll'c  ol  iiiu,,,!^ 
H'  Wllili  li!,M„|. 
,  tllt'V  nil'  IIIMI  . 
,killg}r<'ll,|;il|v, 


V 

— 

o 

o 

^ 

o. 

D 

C 

jv 

ilioiH'pnijro  niinilmi.  of  «i  •*  '^" 

"'^o     (A)  ..11..  Imn,|n„|  ,„.  ,..,,  ,  „.  ,     ''^-  .'^•''       ' '"'  l'l<».,I  is  ,|i|,„,,| 


l-'iQ.  4. 


'""" -—.«...•. ,-, ,„„„„_,, 

•".  *-l...M,K,  ,„„,  ,vi„.„  „      ' "■"■  '"■''""-'""..•*.-« 


Ui 


I'   !)1 


n  f.tifl 


190 


DISEASES   OF   THE    BLOOD. 


whole  fields  for  the  wliites.  Although  the  process  of  counting  and  calc  iLitinc 
is  not  a  conij)licated  one,  yet  careful  and  conscientious  work  is  required  in  did,,,, 
that  the  results  attaimnl  maybe  reliable.  With  the  Thoma-Zeiss  eoi;.  i.p  jn, 
experiencetl  hiematologist  should  not  make  an  error  of  more  than  2  <n  .',  p,., 
cent. 

The  centrifugal  machine  has  l)een  applied  to  blood-counting  in  the  inim  ,,[ 
the  luematokrit  (Fig.  4)  of  lilitz-Medin,  and  is  said  to  give  as  accurate  rGsiilN 
as  the  liiBmocytometer.  Its  clinical  value  has  been  definitely  settlwl  bv  .Indson 
Daland,'  working  under  the  direction  of  von  Jaksch  in  Prague.  The  I.mmkI  i. 
mixed  with  an  equal  volume  of  a  2J  per  cent,  solution  of  bichromate  oi  |)otas. 
sium,  or,  as  some  i)refer,  of  Midler's  fiuid,  and  placed  in  a  capillary  lube  in 


Fig.  5. 


hcen  made  wli 
'viij)y  44  to  6 
,51.6  J -S.  TJr. 
I'liwiiir  in  the 
"lilt  '■'  volume  t 
Uk  Wliere 
laiioiit  one  vohii 
Ionics  Of  (-our 
[jnilimio  of  red, 
[h'W  )■-  a  saving 
x\y  lie  i-ai.s(.(l  t, 

l;r;iv(';iiia'mias,  fi 
(v.Jiiiuc  of  t)i(,  („ 


[irlK'ii  certain 
|«iil 


Gowprs'  n:riii()(.'liihiiiiiiiu't('r:  .1,  fliisoil  tube  iMmliiiiiiiiK  tlir  stiuuiard  mixture:  /.'.  Tul"  in  wl.ioli  liJ 
bliiod  and  water  aro  mixed;  (',  I'ipette  for  colleetin),' the  blood  ;  /J,  Bottle  and  pipriH  for  ili>lii:ej 
water;  A',  I.aueet  for  obtaining  the  bluuil    (l.imbeeli). 


Ill'  nil 


ini{i 

I'c  gt'iieraJly 

If  t'minierati, 

alpiii'/xw.     Xo,. 

Silliiiclic. 

Examination 
%•  ^,),  ^fiilassez, 

|i.fiii()iijeter  devise(i 

''^W'S  there* go  w 

■*i  to  very  eri-oneo 

rtioiis  with  distill 

<"'T''i'  in  a  s(.c(.ii 

"»"'«''-''^v,  a  w(.,lg 

"*'  I'lc  two  cIk, 

""'irt'  <if  li.-eniogloi 

'«■  «itli  Ww  aid  „ 

'.V  I'oiKains  a  littl, 

» 'I"'  ■^<'alc  of  von 
•'^■"ig  counted  {\ 

»'^ 't  i'^  «isy  h,  ,,.,ie,„ 

''"i',i!'li>liiilaire) ;, 

'''■''itiii,  /onus  of 
rii'Tcaiv  ti„i,..s,  J,„ 

"''■"'' 'I 'I'lfilitative 
"■'■''"'"■••^f  'l..neby  n 
"^'''  '"'en  iiiv,., 

"•''"'''•'  poison  in, 
""'•■"•"scop,.  (I,,. 

ed 


the  hfcmatokrit.     The  wheel  is  then  turned,  and,  the  tube  revolvintriit 

of  ilOOO  revolutions  ])er  minute,  the  red  I)loo(l-corpu,<cles,  being  i' t;iti\i'l^"B  The  Studv  "f'n  • 
higher  specific  gravity  than  the  white,  go  to  the  periphery,  and  tlir  voImiik  "  ^ 

read  off  on  the  graduated  caj)illary  tube.      A  long  series  of  exp'rinioiit- 1 

'  Forlschrilte  iter  Mcdirin,  I.SIH,  Nos.  20  ;  nil  21. 


r'-'-it  i-t, 


;:"'"''-""='i.vsisof  fi 

"''^""'^'""'ofj.repar 


r^^TRODU(,j,j^^, 


'  'in lev 
■l';riiii 

■    •"'  PIT 


'"<■     \V^JK.,.e   the      T     '  "'  ^'"'  '-""atokWt  Junl    ,  r  !"  c '"  ""■'''■"-^'•"'  -• 
I  •    ^^'''■•''•^^'^locKl  (.allowed 


'f   i! 


M 


192 


DISEASES   OF    Tin:   JiLOOJ). 


0,  Sluiiil ;  ^1.  (•pciiiiii;  into  wliicli  tlu'  (iiiiililr  ctiiinilior  tils ;  c.  While  plati'  1'    -i  wliicli  li^lii  is  nSiiioi  I 
tlmuiKh  Ilii' cliainlH'i' :  (/,  Fraiiic  villi  llic  ui'duf  of  cnlDrcil  u-luss  wliicli  imsscs  iiiulir  iln- cjiaiiiif, 
(,  Sci'i'u  liy  uliii'li  the  jilass  is  muvcd  ; ./',  [Imililc  clmintHT  whicli  licjlds  the  lilnml  ami  walor;  (/, i.a[.il- 1 
lary  luliu  to  collucl  llu'  lilooil ;  A,  riin'ttc  lor  adiliiit;  tlii'  vvatiT  (l.irdn'ck). 

t(i  ,sj)rt'a(l  out  into  a  thin  layer  between  two  cover-slips,  wlileli  ai'e  then  (|iii(kiv 
separated  and  allowed  to  dry  in  tlio  air.  Foreeps  (see  Fig.  7)  are  used  t'drimlii- 
iiig  the  eovcr-glassos,  since  the  moisture  ot'the  fingers  alters  the  shape  nl'tlnrir- 
puscles.  Specimens  so  j)i'epared  may  be  set  aside  in  labelled  boxes  and 


cxaiiiiiinl 


Fu 


Koriiis  (if  Kon'i'ps  lor  liiddiiin  Covor  ^InsBt'S. 


atleisin-c.  J] 
Mil  a  I  upper  h. 
[i/ix  I  he  lueii 
•:;ii|iiiig  Hnid. 
;ic.«  ut'  "  speeii 
iH'iiaviiir  (own 
•nliiltilily.      11 

li"llH'lM'|;itlll'e  ;i 

■•'.  iiciilral  sah.- 

ilii'iii'id  part  oi 

"•  -raining  pin' 

iiir.-ii-caiied  ne 

.ivi'ii  a>  an  exa 

ptaic  of  tlie  tl 

■li-  I'C  ditii'reii 

E'Vcr  contains 

aivfliimd  in  hii 

P'tiVal  (liagiKi 

(I)  The  eosi; 

liiaid  in  cells  w 

'rniiiid,  liijrhlv  n. 

till'  acid  group 

piiiiilcs  are  nuu 

Willi  alhiiniiiKiii 

'("pliKin.      'i'lic 

tliiiity  [\)Y  eosin 

(-')  l'>asophiIic 

'|"«i  u'lidse  gran 

NllllKill    eiionirjl 

(•5)  Tlic  neiitiv 
li'',i;Taiiiilations,  ; 
'"■  tiiii',  and  re.- 
''■'iii  ill   the    iieiit 

i-'ii. 

\  irclmu  in  ISi 
''"'''  tliaii  tweiiiv 
'  ■'  'iiurpiiiil(,y.i,,.,| 

'■"'ij'-^.     Ill  iiorina 
'"'"l-i'Mrpiisrlcs  : 

("I  Llllilji/l(iiu/tvK 

'"i'lir  lai'ov.  n.nni 

*;■'     TIhw  arc   del 
[»!'  -'«>  or  ;i(,  ,„,,,  ,,, 

^'oi.  II.  -i:i 


JNTRODUVTlO?r 


;it Ic'iViirc.     Hcforo^f'ii'iii'....  *i 

■"= PI- ''=..•)  ^^;;:::;;!;:';:r;:;;;;;;;::rv^^ '''"•■'' ^^^^^ 

'■'ix  '1.0  ln.n....|,.l,i,.  of  <1..,  .,„,  ,,;.:',':'  ^"""I'-.a,nnM,-120°C.,  in  ..nlo 

"-•f  '-N-'i'lo  gnnula,io„s,"  tho  ,     J       r        ^  '''""'"•''  '^"'^  ^^.n.!  vario- 
'"■'-""■  ^'-"•<'  -t-M  grnnps  of- .t:^;":'^'^''''"!'"-  ''!-■' ^''<'i-l.-ifi^^ 

-""""'"f"'^  at  H,st  >ni.k.a,li,.g,  si,,..;  nuT^T  f  "'''^'  ''"''  ""<'  ''-sir-a 


liicli  liirlil  is  r.'l!i"l(4  ^■p-''' 

iiiKlir  tli(  c'liaiiiit'-  IBiiI'  .||, 
)(1  mill  u airr : '/,  i;;t|4l'  ^H 

^llllilli 

ai'c  tlici  (|iiickiv 
ii'o  used  tiii'iinlil- 

si, ape  (it'tlii'ii'l- 
CCS  ami  cxaiiiiiiiij 


---^i—.  ^^-n,l.i,,an,:  :;    ;'f'''^''^^ 

->'  -  ■'"  ,.xa,..,>i.  .,•  th,  fi.,t,  rosa,,iii,/' ;""''';'';;'''''"'"  '"■'•^'*"  '"'^'-^  >- 

''-  "'■  ''i«^"'^'"t  a.,i Is  sc.v,.„  ilHini,!!  ""  '''''"  "*  '''■"""-^'■at."  in  t],. 

'™' '""faiLs  ».o,v  tl,a„  a  si,,..!,,  v,,,-,,,".  ,''''\  J^'-a"Niatin„s  ,•  o„o  ,.dl 
,vlnu,„l  ,„  h„„....,:   i>|,....l.  a„.l  ..Mlv,w,;j,.,v;  ■)   ''"V   ''"■  "'^'"■^'^ 

rariral  (lia.ir„osti(    value:  '  ""  •         ^^'^'"  ■"''"'^^■"  to  be  of 

I    'I)TlH.onsi„o,>|,iii,,„,  «-„,,,„„,,^i„„       , 

H  '"  «vlls  with  /i,i,.|v  la,...v  H„,|,.i  ul.l  I  •  '-•    '    (•^)-)      'J^J"""^  >>^ 

pniilcs  aiv  ,„a.l,.  „,,  ..f  ..(.itl,,;,-  /:„  ,„„.  i,' "       ';''"'"   ''as  pn.w.l   that  these 
-"•      '•''-    grannies  a..    .J  1-    '   T^;'''''''^  -•^-"  '"'  ^1-  cell-p,.,.- 

(2)  Hasophilie.   or  ^-^r,,„,„l,,tio„.     O,,],.  ,„,,,.., 
F""'«''"-  J,n-annh.s  sta,„  o„|v  ,,■„,  „.,,;.    ',    •      ""■^  ;"'"  -"  --'Is  i„   the 
"'"""""  <'"on^^h  i„  the  "  „,ast/ellen  "     c  .,  ''     ^""^"'''  ''"'"  ^''a'^latio,,  is 

ri\   'V\  .  I  .,.  '  "'     '■"'    tissue*: 

'■^^   '"'."'•""•"l>'"lH.',..re-,,,.,.a„„la,io„.      This  i    ,1, 

,^nmnlat,ons,  and  is  Io„m(I  i„  ,h,,  n,.,io,-ifv    ,•  i  """^  "",.,„.,a„t  of  .,11 

^-  «-■  an.I  .vsolvahh ,.   .^^12       7T     ''^'■•■^-'•''- are 

"  i"  t' antral  <lve>--.:  .    •        't      "'""'■;"'  ^''"  '"■■— I-.     Thev 


^ '''''"'^^  '"  I'^b-.  |„,in(,.,|o„ttvv„f 


, "'"^*"  '""""■"  <"'f<"ofo,,„s  of  le„eoevte.      ..1 

'"■^''""  '"""ty  yea,:,  lat,.,-  Max  Sehnlt.o  e.,..        f       7         """"•'  "  •^'"""• 
'  "-•Pl-l0..i<.al  ,„.ity  i„  the  leneoevt  f..,^  •'  '  "  '"'^  "'*"  """  "'>-«'e 

"r ' •'-'  '•'-'-'  -'  now .iisti....;i  h  irisr'  """''•.•''--<>"  i->to 

"^-'■<>vvusrhs :  ''"'  "  ^'"'  'onow,„ir  va.-ietios  of  white 


(")  /,'/m/.Ao<.y,,s..-S„,all  ,.ells  al.o,it  th,. 


r'f'  ;•'■  '■•■•'  l>loo.l-,.o,.,„:s,.|,,s,  ,,. 


"""""^  l:ir.v.  ,.o„„,]isl,,   .leeplv-staini,,...   ,.„  ,  M      ''•■'""•""'-"'•pnsch.s,  ,.,.„. 

':;-^' '•-"t.ofthewh.J      •'^;7r'''^'''''-<'y-a,,dLk^ 

I        Vol.  11.. .i;,  •     ""■^^^'"'  a  Jaiw  oval  orovnM   r-.„i.u. 


! 


mm  ii 


194 


ni.Sh'ASKS    OF    THE    HLOOD. 


•staining  nucleus,  an<l  ii  relatively  well-developed  pnitoplasni  which  d.  .  -  i|,,t 
contain  <>;ranulcs.  (Plate  I,  Fig.  1  (c).)  Khrlich  iu'licvcs  that  tl..  v  mr. 
gradually  transformed  in  thecirculatinghlood  intotiiesnialler  polynuelcii  i  .rm.. 

('')  Jjcucoctiti'x  irit/i  J'n/ipnnrplioiiH  Xuc/ci  (the  so-called  "  jmlynuclea!  Im- 
cocvtes). — This  is  tiie  most  common  t()rm,  since  they  represent  two-tli  m|<  ,,| 
the  whole  number  of  white  blood-corpuscles.  (Plate  I,  Fig.  1  («',').)  Tin 
are  smaller  than  the  largo  mononuclear  elements,  and  are  characteri/ed  liv  li,,. 
irregidar  forms  of  their  miclei,  which  take  all  sorts  of  shajies — S,  V,  Y,  Z.  (.!•[ 
•ThtMr  protoplasm  is  thickly  studded  with  tine  neutrophilic  grainiks,  >,,  tlmt ; 
they  are  often  called  "  jxdynuclear  neutrophiles." 

((I)  TrumitUm   Formn. — These  cells  are  similar  to  the  large  moni.iiucli;!! 
cor]iuscles,  but  differ  in   having  indentations  in  their  nuck'i.    (Plate    j,   \\ 
1    {d,  (/).)      Krhlich  regards  them  as  intermediate  forms  between  h  m\ 
The  mononuclear  cells,  together  with  these  transition   forms,  represeiii  ;iliniitH(,it„jj  and  will 


vary  l)ctween 
mid  ill  youth 
,ikii(i\vn  voli 
Imt  f.'ikes  up 
vlil.'iu,  wJio  p 
ill'  tlii'/i   adds 
ariiuiid  in  tJie 
urdinary  way  ■ 

"<•-  of  ("ami 
uioiiaiy  ])htiiisi 

/'/"  A//:a/m 
line,  ijiit  the  an 

'   piltllo|()jiri(.r 


6  per  cent,  of  the  whole  number  of  leucocytes  in  normal  blood 

(<■)  Eosinnithi/is. — These  are  cells  of  about  the  size  of  the  jwlynnelcar  Ic 

cytes  with  variable  nuclear  forms,  and  a  protoplasm  containing  large  rdVaitiv.' 
eosinophilic  granules.  (Plate  I,  Fig.  1  (/).)  They  make  up  from  L' to  1  |„.r 
cent,  of  the  white  blood-corpuscles,  and  have  their  origin  probalilv  in  -;,, 
bone-marrow.  Fnrms  />,  c,  an<I  </  are  said  to  come  from  both  -pltvn  m,, 
boni>-marrow. 

The  proportions  of  the  different  forms  above  given  ari'  fairly  (dii-iimii 
health,  but  mav  vary  widely  under  ditfereiit   pathological  conditioii>.     Hi 
a  "differential  count"  of  the  leucocytes  may  l)e  of  very  great  yahic.  a>  I  - 
show  later,  in  the  clearing  up  of  the  diagnosis  of  a  difficult  case. 

In   some  diseases  cells  not   normally  ])resent   in  the  i)lood  at  .■,11  iiiav 
found    in  dried   -pecimens,  and   the   presence  of  these,  together  uiili  (ciiai 
deo'cnerative  and  regenerative  forms  of  red  lilood-corpuscles,  to  be  ,-|Hik('nii 
later  on,  are  signs  hitherto  insutticii'iitly  appreciated. 

It  would  be  going  beyond  tlH>  limits  of  a  general  te.\'t-i)ook  to  ivtir  tn  n 
the  various  staining  methods  which  may  be  advantageously  used,      flic  ml 
ing  mi.xtnre  of  greatest  j)ractical   yaltie  is  perha|)s  that  known  a-  tin'  nipl 
stain  "  (  Khrlich-i^iondi).      It  contains  methyl  grc(>n,  acid   fuchsin,  ami  maiii 
(r.       With  thi-  tluiil    the  miclei   of   the   white    i)lood-corpuscles    arc  <t;iiiii 
u-rceii,  those  of  the  nucleated   red  blood-ciicpuscles  nearly  black,  the  ml 
j)uscles    themselves   orange,   the   eosinophilic  grannies   red,  tlic   iii''ifi'"l'liiiBiii->  in  iiieiii<  < 
granules  a  deep   violet. 

'Tie  plasniodiii    malaria'   may   be  '^ndied  in  dried  speciiiirii-  -laiiuil  'wl 
I  1.  Im's  solution  of  eosin  and   iiKthyleiie  blue,  but   tliese  bodic-  ■■■>n  \«-  ixm 
iiied   much   more  satisfactorily  in   the  fresh   blood.     The  stainin 
oriranisms  in  other  blood  infection-  ('•.  [/.  the  tubercle  i)acillus  in  aciitc  mil; 
tnberciilo.-is)  gives  results  too  inconstant  to  be  of  niuch  practical  ^  liiii(';il  val 


'flic  Esthnati 
ippmxiiuate,  an 


The  older  w 

lf|MH(liiig  eitJier 
or  "II  an  increase 

liii,t;iii<lied  ;!  ( 
'dirtliora  apoco})! 

r  lifi'iiiorrliage 

"f  fllll-bj.KHli 

'fmin:  red,  tiie 
Minding,  such  j)a 
[itfiincs  from  attai 
jfri'W  (lifllTcnt  mu 
Msiifiicicut  ^^y 
i'*''  iicen  siigges 
*' '  'elinlieini  on  ; 
'liionV  cdiidition, 
«iiifiti<-  of  transi 

l"^till  t\V,M„-    III,., 

lie 

*""l-ili>fi'ii)iiti()„  tj 
Tlic  n>v.  „f  1,1, 

*'ls  :'-  ill  clioler 
Iptlmra, 


Accessory  Methods  of  Examination 
The  Spccltic   (iriirHi/. — In   health    the  s[)eoitic  gravity   ot  i 


hliiiiil  iill 


■'""■'ilia    riijty  [ji. 

■"'""■•    -pendent 


f'J^KTIfORA. 


1!)5 


vary  Lchvoon  1045  an<l  1075      U  j 

ll"EstnnaUon  of  the  Total  A.nou.t  T^  T  ^''^'  "'^"*''««  P^^vL. 
|w-n.ato,  and  need  not  bo  dc-.-iM  t,     "  '"^  ^■"'   '^^  ''^  '^-^  only 

Tu      .  1  Plethora. 

Ilic  Didor  writers  spoke     f     I    i  * 

¥"''"'^  either  on  a„'  inerea^e  h/d"  l^lt^l^  I '"''f/f '«'<'^'-J  condition, 
;;;;"  -  ;--ase  of  the  red  blood-corp,"  ^  i^^'ll^  ''"  '''"'''  -  ^^-  '-cl^ 
Kn,sl.ed  a  true  pl.thon,  (pleth,  •        ^  '•  r"^'  ^''^  "•"•'-'  li-it.     Tl.ev 

rr  'T^'^'"'  *'""^^'"^   a.np„talio       t'       P    ?  ^-"'I'^-'-atie  pletho,, 

'""■'■''"■"""•••''aj?es  or  in  ,.a,.i.exias)      J        '     ^    '    ""*' =  J^'^^^^'-om  Imlnen.iea 

,  "•"'-'•'-';Hl.".Iness  see..  i„  i.  ,  ^J  :;  'f ";!;'  ^^  --.t  ti.at  eo,.dK 

U- h.o.„  attaeks  of  palpitati.:..  '     ^'''^'^l':'"'^:  ^••■"^'^'-.  -«--, 

■■-if.-nt  ..xe.vise  a.-e  the  n.ost   h.  ^^  ^  1-;  -P'-tion,  ove.-f^odi:;,, 
^;'r;   -'SKo^ted.       The   experi,.,e^       '"   1-  ''"  ^•'"•'--  '-"-^  whiH 
"     "'•"'"-!  -  anin.als,  ahhon^h  tZ  1. " ^  '^''"?;'^/'^   Wor,...Muller 
;"":'!'•  •■-'■t-n.  -io  not  j,„tifV  the  h^lf"^"  '""■'*'''^^-  "''  a  t<'n.po„uy 

"■'.'"  '""  :"•  !'"•<■"  "-'<^  after  i..iX      Th!"      ''^  '"  ''  ''"■  '■''>■''  -''  at 
r  ",""■',;  '^  •'"<■  ™f''-'-  f"  ehan^esi..  t    '  v.  '''""'''''"''  "'"  ^"""-l^^-l^i- 

":  '''^"•''"•'-"  t'-.  to  aetnal  i....,-.,.  J       h:7Tr"'  P'""  ^"'^'•^'"'"-  ^'"^ 
'  "  '■"--  "f  '>lood-,.o..,.en,..ati,.„    ;  11  '■"'""''  "'■  '•'"*'<!• 

t'7r'r-"''--at;;n;;::^^^'r^^^^^^ 

.,     .  The  Anjp.hi'^s 


.1         !  ' 


!,  i 


'h       '  :  I 


19« 


DISEASES    OF   THE    lil.OOD. 


m 


part,  will  not  he  ronsidcrcd  hciv.  In  a  {j;eiipral  amoiiiia  tlioro  may  be  a  'Ijniim. 
tion  ill  tlic  total  anioimt  of  the  hlooc),  oi'  its  contaiiu'd  corpuscles,  or  ofivrtiiin 
otiior  important  constituents,  .such  as  albumin  and  liiumoglobin.  Wlion  t^im 
is  a  decrease  in  the  mimher  ot'red  blood-corpuscles,  we  speak  of  an  olij^v,;  vtlu,.. 
niia ;  when  the  amount  of  hserioglobin  is  low,  the  term  oligochronin  rnj;,  |, 
used.  Very  often  the  oligochromaMuia  is  about  proportionate  to  tln'  uli._r,,. 
eytha'uiia,  lint  in  other  cases  the  relation  is  by  no  means  e(pial  ;  this  relaiiim  j, 
generally  rpioteil  in  terms  of  the  amount  of  luemoglobin  in  an  individual  (up- 
puscki — Id  ra/c'/'  f/lohii/dirc  {){'  Le[)ine. 

Not  every  pale  jierson  has  a  general  ana>mia.  There  are  individual-  wIlk, 
persistent  pallor  of  the  face  i.s  due  to  hereditary  iuHuenees  or  to  local  vmm,. 
motor  disturbanoe.s,  who  may  have  their  full  complement  of  corpuxles  ami 
of  lijemoglobin. 

Patients  who  have  any  advanced  degree  of  antpmia  present  a  charaitciistic 
set  of  symptoms — viz.  pallor,  shortness  of  breath  on  exertion,  palpitatiii'i- 
of  the  heart,  headaches,  and  in  women  men.strual  disturbances,  ukki  (,t't«| 
amenorrhcea — svmiitoms  which  alwavs  demand  a  most  careful  bloud-i\aiiiiii;|. 
tion.  Even  with  the  marked  improvement  in  the  hajinatological  teeliiiii|ii(.  ,,1 
to-day  it  is  often  difficult  to  pass  judgment  on  certain  obscure  cases,  and  ali 
classifications  given  are  at  best  only  provisional.  It  will  be  found  coiiNciiicni 
to  .separate  the  so-called  primary  or  essential  ansemias  from  the  secoiidai'v  m 
symptomatic  forms,  it  being  understood  that  what  we  now  call  primarv  mif-  \ 
mias  are  so  only  because  we  are  as  yet  unacquainted  with  their  exact  etiol(wv 

The  Primary  or  Essential  Anemias. 

Of  these  we  have  two  distinct  forms — Chlorosis,  and  Progressive  IViiii- 
cious  Aniemia, 

CHI.ORO.SI.S, 

Definition. — An  affection  occurring  chiefly  in  young  females,  wliith  pin- 
duccs  clinically  the  group  of  symptoms  common  to  the aiutMuias,  and  i-  char;;. 
terized  by  a  marked  diminution  of  the  amount  of  luemoglobin  in  the  imliviil. 
ual  corpuscles. 

Etiology. — The  great  majority  of  cases  oeciir  betw(!en  the  ages  of  f(iiiitnii| 
and  twenty-four — a  fact  which  gives  some  supj)ort  to  the  view  that  llnri'  i>;i 
intimate  relation   between  the  affection  and  the  changes  which  the  mvaiiH 
midergoes  at  ])uberty.     In  girls  in  whom  the  disease  occurs  early  in  their  treii-l 
we  are  aj)t  to  find  a  certain  precocity  and  an  almost  premature  ap|i(ariiinrH|' 
the  mcn.ses,  while  cases  occurring  later  are  associated  with  a  histrnv  (if  a  lato 
puberty.     .\s  a  rule,  the  pallor  begins  a  year  or  two  after  the  nieii-i<  arc  lii'-i| 
seen,  and  scanty  meiistrunlion  or  total  amenorrhoea  is  a  concomitanl  '-vmptHiii, 
the  mcnorrhagic  chlorosis  of  Trousseau,  as  fiir  as  our  experience  uncs,  hoiii^'l 
uni'ommon.     (lirls  with  light   hair  and  fair  complexion  ,are  more  liwiiicntly 
attacked  riiau   lirunctU's.     'I'he  affection   is  rare  in   males,  though  -ijiac  iM-e- 
occurring  at  puberty  have  lieen   reported. 

Virchow  has  advanced  the  theory  that  a  congenital  hypoplasia  uf  tluMi-j 


cirLORosis. 


u,>i;i  uf  till'  vai- 


*--:''t:';.:::J::;;'r:::--r:r"" ^ '- -^^^ 

Ilia  Inm.  Hilorosis  .Mf  tl..  s,,.,.,.  fi,,,,.   "  Tl|  ,    *''"''"'"""•"  ■^'■^t^'''^ -"HiT- 

,|„||v).  '         -^  '•'""'■'■>   ••'•nu.nnnah.l    witl.    tubcnM.lo.is 

,  ,    \  l";'":"->-  "••■■VMS  „ngin  is  dai.nc..|  In-  so,,,.  u|,m  ,.,>,   •     , 

' -'"''•'^- "  p'-ti-  t-n.,  io..  5.i;!;i:";!j  "';^  m,,.!,.,,,,,!,"  .,•  .hai..,...,,,  ,,l 

'Hr«'^  ^-Hl  <.r  ,„ast.„-l,atio„   l.avc 'it  "soon    V         >   '"  "^"  ""'"'''"^''  '■'■^""' 

ip-y  p-i...  a  la,,.  p.-opo;t;ir:" ,.  \:::.':;:  ;-"7-'--.'.  m 

i»''iiiM,u-  ^«'wmo.-.i,.is  or  lk.t.„T-opo,-ativ,..    u- ,  ""'  "'"""-   '""■''- 

r«.M,s.  a„.l  havo  s™al  fli..|„s  of  .    ;,         ',";'"""''^^'^^''  '""'    '-lly-]i,d.t..,| 

,-^'-' ^-  ='"  i.y.i-.^.  lat- ;;;:;:  ;r7^-  f-- ,  ^■•'^^' « eo.wa„t 

lr.n,  ,l„.  ,.ulo„-a  t,.„.  ,.„,„,,,„„    "'  "'^  "^  *''^'  "''-'•pt'""  of  toxic  {„.o,l„c,s 

Morbid  Anatomy.-Tl.,.,,atl,oloi.v  of  ,.I,Ion,sls;    •  .     , 

l>H-  cMMs  .lie  ,iin,.tlv  fro,,,  tl,  ■  ,ii.,..,  :        I  ,  '  ""P<''-^«'f  v  un,l,.,.stou,l. 

\ h  Lav. to  autops      l:  '   ;  :',::t  '"■  '^"^'""'"^''•="   '-•''"^>  i"  .1.OS0 

[^^•'  i-nt..l  o.,t  ....,ai,.'  insta,.:J     "i     ,  :;;, i::;;;  '"'"r"'--      '^-''<ita.,.k,  i,. 

'■  ''';'<i— Is  a„.l  of  tl.e  ,...;,.,  o,..  ,     '    Vi        r:;  ''"7->"-alies  of 

h-ph,s,a  of  tl..   vas.„lar  svst.,.,   fu,,.,!   i„  •'•■■^<''-'l'"<l  ^ -o,.,<,.,.ital 

Wi^"t-     Th.  ao,.ra  a„<l  all  its  |"  ,  "'T      '""''^"^  ""  •'''"'■"*!•' 

,'-  -"'■■"-•=  tlu.  .lastidtv  o    tl,    ;"1       T"  *     ""'"  '■''"'■•'■  '""'   ^'-"- 

I"-n..of  l.is.as.s,  l...t  liv  „.,  ,..,..^  ;     ^  "h"""''  ^•''"■"■"-'  '"  '""  '"-•--'• 

fypm,.,,!.;.,!.  ^"*"'  ''^  ''^  '■"'^■^  <''J"f«'<I  a„.l  tl,.  K-ft  v.„tri<.l. 

Symptomatoloffv. — Tli.  m-i.,..f->. « 

■"■-•  >: >=  .i.-i " Ilvt';:;;:  -.n:!;;:;::!:: ™'^"  '""■''■■- 

h^.inanL..iot.s...ot,,^;,:;;:::,t^^^^^  m... 

!"■  M-ina,.  is  bc,,ed  to  di.-..t'l.is  tt^u       ,    t:;;""^"^  ''avo  ceas<..|.  a„.l 
I'li'finii.  t'L'itimnt  towai-d  a  r.storation  .,f  this 

^lifgciieial  symptoms  of  .hlui'osis  •„•..  ,1,  r 

nju.usis  aio  those  ui  an  ana-mia  of  a  moderate 


I  its 


DlSK.iSh'S    OF    TIIF.    /}/.<>(>/>. 


orailc.     Till'  p'ltiont  is  !:;om'i'ally  well   iiiniri<li('il,  and  tlic  |iaiini(Milus  aiil|M,.iH 
rather  increased  than  diminished.     Tlio  skin  in  many  eases  has  a  charact.ii.tic 
"•reenisli-yellow  tinge,  (iiiite  diiTerenl    i'n.ni   tiie  hianciied   asi)ert    prmhi,,,!  I,. 
hiuniorrhage  or  the  mnddy  paHor  of  the  graver  forms  of  anu'inia.       Ii  i>  ti, . 
eiirions  tinge   of  the  eomph'xion  which   has  given  rise  to  tiie  popuiaf  nimy 
ol"  "  <n'een  sicl<ness  :"  it  mnst  Ix'hornc  in  mind,  however,  that  in  many  iiaticni-. 
nndonhtcdlv  elilorotie  tliis  sign   may  not   be  marl^ed.     Aside  from  the  ham,,. 
metric  examination,  the  degree  of  hiomogh>l)in-poverty  may  he  judged  I,,-;  ;,y 
examining  tlie  eohir  of  tiie  palpebral  conjnnetivic  and  that  of  the  matrix  utili, 
tino-er-nails.     The  lips  and  cheeUs  may  be  of  a  rosy-red  color  on  exert  inn,  cv,:, 
wiien  the  valeur  f/lobiilaiir  is  considerably  diminished  (chlorosis  rubra).    Tli. 
skin   about   the  joints   not   infrciiuently  shows  areas  of   pigmentation.    Ti, 
breathlcssne.-^s,  palpitation,  and  tendency  to  fainting  are  evidences  of  tlic  insiitli 
cient  oxygenating  power  of  the  circulating  blooil. 

The  "symptoms  referable  to  the  digestive  system  arc  often  interc-iiiiLr.  |: 
some  cases  the  functional  distnrbaneos  are  so  marked  that  many  author-  -pdik 
of  a  '■  dyspejUie  ty])e"  of  chlorosi-^.  The  apjiotitc  is  i>oor  in  many  patients— iii„i, 
often  it  is  perverted,  the  girl  refusing  to  eat  ordinary  articles  of  diet,  but  luii:- 
ing  for  unwhttlesome  dishes  like  pickles  or  other  highly-flavored  foods.  S(h„„|. l 
irirls  have  been  known  to  eat  quantities  of  the  mo.st  indigestil)lc  substiiii(v<, 
such  as  bits  of  chalk,  slate-pencil,  or  (<ven  earth.  Vomiting,  or  rather  rcj;i:r. 
citation  of  food,  in  the  mornings  is  not  uncommon.  More  than  once  imtini;. 
have  come  to  me  fearing  that  they  were  pregnant— a  fear  perhaps  uoi  nnii;itii!;il 

in   iiresenee  of  the  three   eontlitions  of  exposure,  amenorrluea,  and    niiii;| 

vomiting.     (Vmtonrier  has  found  a  dilated  stomach  in  many  chioroiic.s  ai, 
believes  that  it  is  .sometimes  a  cau.^e,  sometimes  a  result,  of  the  disca-c     l'iriv| 
of  Prague  goes  so  tiir  as  to  attribute  chlorosis  to  the  absorption  of  toxic  pr,,,]- 
nets  from  the  stomach,  and  claims  to  have  siieeessfully  treated  inaiiv  .i!' '  ^^ 
cases  bv  systematic  lavage. 

Weliavo  already  mentioned  the  freipieney  of  constipation  in  chloin«l«.  :i. 
well  as  disturbances  in  the  menstrual  function,  which  are  extremely  ciiniiinii. 
The  amenorrhooa,  leucorrhoea,  and  dysmenorrha'a  generally  disajipcar  vAyM 
under  treatment  directed  toward  the  defective  condition  of  the  blood.  Nin-i-i 
symptoms  are  more  prominent  in  some  cases  than  in  others.  irradachc  p;ir- 
ticularlv  the  vertical  variety,  is  especially  often  met  with,  while  niiiraluin  ai^l 

even  hysterical  manifestations  .sometimes  occur.       Fever  is  not  ( m<nu  Imti 

there  are  cases  (febrile  chlorosis)  in  which  there  is  a  daily  ri.se  of  teiniMi'MtiiP,! 

The  changes  in  the  vascular  .system  are  more  or  less  charaeteri-tir,  and  ilief 
palpitation  of  the  heart  is  at  times  most  tr<.ul)tesomc.  On  phy-icii  cNainiiNij 
tion  the  heart  may  be  found  slightly  enlarged,  and  murinni-  mav  iiiaril 
alwavs  lie  iieard  in  the  severer  ca.^es,  the  most  common  beiii-'  the  -.v-t.iii| 
souffle  at  the  base,  usually  in  tlie  pulmonary  region.  More  nuvlv  a  wliitl'unrt 
the  tirst  sonud  is  to  be  heard  at  the  aix'x.  Durozie/  atlirms  stoutiv  thai  tliH 
murmurs  mav  always  be  distinguished  from  the  murmurs  of  ornaiiir  'I';' 
ear-v.     He  claims  that  while  the  latter  are  still  plainly  heanl  when  tlir  «ir  i 


liioiid-ilinri  ,i(  I  lit,,  of  (^ 


('l//.()/,'OS/S, 


m) 


ill   rliliiru-l-.,  ;i- 
'llll'lv  ('(illlUlMll, 

«a|)|i('Mr  [■iipiiliyj 
ill  II  III.    NVrv.  :iJ 
llr;|ilarhr,  |i:i!- 
'  Mriinilu'i;!  aiiill 
It  I'linniiiiii.  !i!it 
it'  irin|)ci'iitii!'i| 
cri-tir.  Mini  i!ii| 
v-ii':ii  i'.\;iiiiiH:i-j 
ir-  iiKiy  iniirHl 

tin'    \\\V    -V-tiiiill 

civ  II  wliitf'wi'ij 
lUtly  rliiit  tlifi 
f  iii'j;;iMii'  'li^ 
vlini  the  iMl'il 


ivmiivcd  a  liulf  dishinrr  fn.iii  li„.  vUr.i    i\,     r 

'-'■''  '"  "-"•■•vi-al  veins       T     'i        ;:'-"""^"  .  " '"'""   i'''>l.,"  is  ..It,.,. 

-M-ients,.. n  .:n.p,:i;;'r ;;:;;:  ;;;;;r^  ^;' "-^'^ '■'/^"•- 

vm"i-'l  '»'•  bnicliii.l  veins  vvl  ,.,.„  if  ;       \         •  '^  '"".''  "••'''"•  '"  <1'" 

t "I »'"'--' .::^:!;:.:,::tn:;;;;:;™"''-' "•■ '-- 

.«™:;:::;™:;:;:'"'"^ "■■-« -'-'i.-,:,, ,„., 

I  III-;  JJrooi)  Ev  \Miv  \ii,,v      'ri        111. 

I »i«.,  ai.i,„,„i,  ,':.:-'";;"'  «'"'""•-  '":'.;■ '- 1 ™<  i" ™„i 


Fro.  8. 


Ill 


ME4W 

NORMAL  NO,  0^ 

WHITE 
CORPUSCteS, 


"""''""''''■''^'•''^"■''•''-^'-^''--^^ 


"'.  '"'^l  '1-  average  .,ua,.t.ty  of  lue...oglol,i„  was  42.3  jt,.  ..„„t      Tl.i 


!  m 


V    1 


i 


J  • 


I 


2(M) 


DJSKAsi:s  or  tin:  lu.uon. 


rclativclv  jircat  oliu'iicliimniciina,  tir-l  poiiilcd  (Hil  hy  Diiiu'iiii,  is  tlioili>tiii  ui,||. 
iiif;-  cliiiiactcristic  ol'tlii-  hloiMl  in  t-lilorosis,  and  .-crvi's  t(i  ditU'rcntiatc  it  ~ii;ii|i|v 
from  (list'ast'.s,  like  pcrniciuns  ana>niia,  whrrc  tlic  .;lul)Mlar  valnc  in  liuMnnLiluiiiii 
is  incrca.-^cil.  In  ono  case  tiic  olijfocvtlia'niia  was  severe,  liiei'c  bein-  mi],' 
l,95;!,ll(M)  icds,  witii  17.")  per  cent,  of  lia'inoj:;li)liin.  'I'lie  white  cell-  u,|, 
onlv  sliii'litlv  increased  in  innnher,  avoraji;inji;  in  the  alxive  O".  case.s  8407  lu  ||,.. 
cnhie  iniliinieti'e — /.  e.  1  white  to  40S  red.  ( )ne  ease  with  over  85  pi  i  ivin. 
of  red  ulohuh's  and  only  -'}•")  per  eent.  oi'  lia'nioij,lol)in  pnsented  aecnrati  Iv  lin. 
clinical  aspect  of  a  pi'ofonnd  aiueniia. 

If  a  drop  of  fresh  Mood  l)e  examined,  the  pallor  of  the  individnal  .  iir|in,. 
ole.s  is  at  once  apparent.  There  may  i)e  niiniy  poiluloeytes,  by  whirli  ^vc 
mean  defornieil  red  i;lol)n!es  assnnun^j  the  most  eiirlons  flask-like,  hiiiiiinii.. 
siiapeil,  or  pyriforni  appearances.  In  the  dried  and  stained  specimens  a  >iiiai| 
mielcated  r-d  blood-eorpusele  (the  mirmoblast  of  l^hrlich)  may  now  aiul  tlicii 
be  seen.  (Iriuber's  determinations,  accord inji  to  Landois's  proeednre.  sJKjWdl 
a  diminution  in  the  alkalinity  of  the  blood,  l)nt  investijrations  by  more  ;i(vii. 
rate  inetiiods  have  not  eontirmcd  this. 

Diagnosis  and  Prognosis. — When  a  yonug  girl  comes  to  ns  wit!  -iidi  in 
arrav  of  symptoms  and  com|»laints  ,(  <■  lionld  never  assume  the  re>puii»ilii|itv 
of  exeludinu-  a  urave  aiuemia  bei.  ",  .Miking'  a  careful  blood  exaininatini, 
althouuh  the  diaiiiiosls  in  the  uutiociiy  <;f  eases  is  tolerably  easy.  TlHivap 
eases  of  secondarv  aniomia,  however,  with  considerable  dinnnutioii  in  ihc  cnr. 
])usenlar  luemojilobin  value  :  this  is  t'specially  true  ot"  the  ana'mia  i  I'  ihcia:- 
liest  stages  of  tubercMilosis  of  I' (■  bniiis.  One  should  always  satiety  liinhilf 
that  the  lungs  are  clear  before  giving  a  ])ositive  diagnosis,  an<l  organii'  ili^cax- 
of  the  heart  and  kidneys  are  to  be  excluded  in  the  ordinary  way. 

The  prognosis  is  always  fav(;rable,  except  in  those  eases  associ.niil  witli 
coutri'uital  anomalies  of  the  vascular  and  genital  systems.  We  imi-t  mi 
however,  forget  that  relapses  are  eon)mou,  and  where  they  occur  it  i~  in  iiiu.|| 
eases  because  the  treatment  lias  been  too  soon  discontinued.  It  is  not  raivt" 
.see  a  reeuri'cnce  diu'ing  the  third  decade  ot'  life. 

Treatment. — Chlorosis   is  one  of  the  few  <liseases  of  which  the  ])liy«i('iaii  j 
is  a  therapeutic  master.      .\    fvw  weeks' administration  of  iron,  together  wiili 
an  imnroved  hvuienic  condition,  usnallv  sutliee  to  restore  a  ruddv  i;Im\v  tn  ilul 
most  i)allid  cheek.     At   the  outset  the  patient  slioidd   be  impiv-Mil  wiili  iln 
desirabilitv  of  persevering  with  the  treatment  until  the  luemogloiiiii  vilin. (« 
.shown   I) If  ihc  lt<(  iimimfric  f<r(ih',  is  above  00  per  eent.     The  distfc-iii;;' sviiip- 
toms  may  disappear  entirely  at  the  end  of  two  weeks — long  bef  nv  tln'  pir- 
centage  of  the  hicmoglobin  is  normal — and  thus  our  patient  may  (lisi|ipiar  tinj 
weeks,  only  to  return  in  her  former  condition.    In  the  severest  ease  im  Tliaytr'>| 
list,  where  the  red  blood-cor|)uscles  were  below  two  millions  and  the  liii'iiio- 
globin  below  '20  per  cent.,  at  the  end  of  ibiir  weeks  the  mnnbcr-  :.f  rcdswicl 
found  to  have  increased  to  r),{)!)(),000,  and  the  hiomoglobin  to  70  pir  (viit„aiiil 
at  tho  end  of  the  eleventh  week   her  hicmoglobin  percentage  was  '.)'>.     All  lit 
tlio  cases  of  the  series  were  given  iron  in  the  form  oi"  Bland's  pill-,  iwi*  piil^ 


{'" 


Iiedi.-tin.  iii~||. 
tiato  it  -ii:ii|,|v 

ill   illl'lllii-iniiili 

.'I'c  iH'iii-  iiiiiv 
liite  cell-  nvir 

■iCH  84(i7  In  til,. 

c'V  H')  |iii-  ivnt, 
aooiiniirlv  [III. 


i'n(KUN:ssi\/.:  n.i 


isiciors  AX./: 


I//.  I. 


I'fi 


v«'  ^n'aiii 


s  ciicli  iirt,.|. 


"iii'"i"  (u<)  lioiirs   ill  fl 


•■^••■'•y'"..ai.     Til,.  ,,,,„•,.„, 


Ix'lw 


ceil    li<.|' 


";"'."■"  ""•  •'"'■'y,  ami  tu  ,..,k,.  ,1 


"a«    .■||c..lir;i-(.(l  (r 


L'Ol 


-|icil(| 


IllClils     III      (I 


'< I'^c    ol"  tlic    t 


"•'■''   or  I. .Ill'   t;lii>s,.^  ,,(• 


■.r->aiT,  ,-uiis.i,.,(io„   uiis  (natcil   |,v  sij 


\v<'Mty-<(.ii|.   I 


'""'  '"rill  ,.f  ip,,,,  ,1 


""'X     111     tllC     II) 


Kiiir. 


W 


lire 


iv  I'o  tala.n  witlioiit  (h.,il.|,>.     If 


'-"■-"■"'-  "csliiill  nCfcii  lin.l  (I 


ilii'iii' 


}   "f"  IJlllif^y 
I'll  ill  aiiv  fiin 


dctcclcd  Ml  (he  /;,.,.,.s^  I 
ilj.l 


"^   "    Vcrv  |)l;,l|sil,| n,. 

"  i-^  ""'  it-<l/'al.s.,rl„,| 


""■  tlic  iron  act 


•H'lllliy. 

ia(   an.. til,. r 


I'll  pa  ration 


.-*  H    .still    I,|,s,.tt|,.,i,   I,U(     il 


Ffc   l)('li,.v(s  tl 


)nt  sii 


>  -^iiKv  an  ,M|ii;i|  ;i, 


M-'in-jrcn  sniplii.i,,  „,  ,„|,,,,,      ,^^ 


l'l"'^^'N"i'  tluM.fli,.,.  |,,„„|   fl 


lat     lll(irii;.;|,ii,.     j,.,, 

""iiMt  fMii  alu.-ivs  I, 


ami  tliiis  iMTiiiits  tlic  a! 
mI'  ii'uii  wliici 


I'll'"'  ••<>in|>,.iiii,|s  ill  (I 
''•-'"•Ptioii  of  tli,.  liiViii,.  ,,„     , 


'••<'  It   iiiiit,.s  witli   til,, 
■iiilcslinal  lr;„.|, 


II'  yastn 


wv^  as  an  i 


'  ''''f  '"  'i'"<l-.stt.irs,  Mll.l  xvlii.l 


livpotlu'sis,  I 


iis,.liil)lo  .-iil|,|ii,I,,.      ( 


"•vc  put  ii|,„„  tl,,.  iii;,rl< 


•'I'taiD  iiin-,.|||,„,^  J, I 


pl,'\      .,ru;,| 

'  \M'iil<|  ,.tli,.rxvis,. 


""•  <'i'inl)inati 
pass  (itr  i„  ,1, 


(111 


'"  ""■^<'  :"v  all   „i'  <|„i,|,tf„|   ,„| 

;,iriti(Mis. 


'•'  pi'i'paratii.ns  „CaI| 


'•■"■'""••ists,  iii(li„.||,.,,|  1, 


vanta-o.     Tl„.  ,li,.t   sji.,,,!,!   i„.   m 


>iiniiiiat,.  ,,t'  iron 


A:,  tlic  ,uirl  ,<,Ta,liiaII\ 
lai'ciiiit  imcuinnion,  hut  tl 


>i'i'al   an, 


trcMtinciit.      r    I 


i-oiiaiiis  liei-  ,.„] 
'<'>'■  arc  of  triflii 


la 


Fli 


l.-clll 


v»'  tnniiil  th,.  svst 


t»r,  acncifon 
ig  imp,)rtaii 


"  ''I'lipti^uis  on  t|„,  t; 
''•'  =""'  ri"M  t,.  til,,  onli. 


icc 


Itrfatiiiciit  iiiiti 

illlllO  llU'lllO<>-|,)l)ii 


•'  "'•^f'in„.,it  a  valnal.l,.  ai.l 


'■"'"t-  ,>xan,i,iatio,i  or  ,h,,  b|,.,„|  ^^.j,, 


'•'ii'cl,  as  tl 


III  cn,.()iii.;|i,i 


111; 


't'v  grow  iiitcmst,.,! 


I'.'Hiciits  t,.   ,.oMt 


J)<'r,',.|itaij,., 


'"  \vat,.|iii,g.  the  .stca,l 


mil,' 
y  iiici'ca.so 


I' 


it'XiHKssrvi.:  Vkus 


IIS   (ilsca; 


{.NK'KII-S    AX.KMIA. 


•'   "-'s   first  clearly  ,I,.s,Til„.,|  im,! 


■^•'11,    \Vll,)> 


|ffl'nil;i"    \,y    .Vdil 

'•'""■';""■  '•lii.'^sical.     Wilks,  L,.|„,,t  (., 


cr  ill,.  II 


V":"""*  "'■  fl'<'  ••li"i<-al  liist,.rv  of  tl 


'""'  "'■   "  idiopati 


lie 


'"tlif  literal iir, 

i:Hts  (■lini,.al  aspe,.ts,  and 'it  is  t,j  B 


laniiiiiir,  ;,|„|  (;,,, 


If  aft 


CCtlOll 


^'T'!-     ''^'"'^  'S"-,  tlH' dis,.asc  Iia,|  I 


•''•""■all  liavca,|<|,.,| 
"'''"  -^tiiilicl  cliii.Hv 


";.'}  "f  tlic  al(,..cti,)ii,  tl 


lat  \v,.  ,)\ve  tl 


*■""■"  lias  been  stii,li,.,l  l.y  a  liost  of 


'O'-mor,  who  in  IS(J8,  ,lis,.„ssed  tl 
H'  ivvival  of  iiit,.i.,.st  in  tl 


Etiology.— A, Id 


I    is,.rvc|.,. 


II'  palh,)!- 
"'  aili'ctioii,  which 


I.SDIl 


IClllll 


'■■';  :iiiii  111  hi.s  111 


as  ..arlyas   184-3   ha,l  spok 


liv..  Illlll 


III!'  ,'l  iiill 


a  liricf 

1,, 


;icc( 


Allograph  oil  tl 
""It  Dfthis  fi.nii  of 


pDlvcii  of  the  ,1 


"'.  '^"P'-'rcnal  (.aj.siil,.s   pnl,Iisli,.,| 


IIS 


i-'^fasc   in   I 

ill  Isr,o, 


lot 


pcridd  I  lia,I  f 


""I'M'ia,  .ifwlii,.hlicsp,.al<sasti,l| 


,™(.|';il;ina.|iiia  in. 


'•'">'  fi'iK'  to  time  met  witl 


ows  : 


rliii'li  il 


ii'i'i'  liad  l),.,.||  ,1 


*'""mno.  without  any  ,li,,.overaI,l 


vm-  rcmarkahl,.  j 


iNl'H'iisis,  no  pill 
"liilifriiiiiit  ilis,.ase 


P'""l'"fa,  no  renal,  siil 


I)revi,)u,s  loss  of  I,I„ofl,  no  ex  I 


c  cause  whatev(.r— , 


oriii 
fases  in 


Tl 


;''"t'>;nnVlin85,S),  while  tl 


10  nam,.  "  ..ssential 


'■'"<'.   iMiasniati,',  o-lanihil; 


laiistinu-  diarrhrea 


ii'tl  Ity  i;i,.ri 
I'tiiiii. 


ic  term   '* 


aiiii'iiiia"  hail  its  ,,|.i 


•I",  .strumous 


no 


or 


IK 


'■'  "■'"'  thought  lie  was  ih.a'l 


pronivssive  p,'nii,.i 


fill  with  r.e- 


'"g  with  a  pr,.vi,)iisl 


oii'^  aiiiemia  "  w 


IS 


V  link  I 


sown 


ililisoiis  aiuemi: 


pll'tllllc  t(|  I 


"■^gfographieally  wi.Iely  ,]ist,.i|„ite,l.      It 


to  flu.  fa,.t  tl 


;"'Par(icnlarly,.o,i,|„o„  ,-,;  ,| 


"at  It  was  eonliised  witl 


If  (^aiitoiis  ,if  S 


1  ."^ome  of  the  m 


"as  thought  at 
\vitz,Tlaiid,  owing  prol,. 


my  grave  cases  of 


.1^„  *■'« 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


|iO     "1"^^ 


11-25  PI.4 


1.6 


<^ 


%■ 


//, 


^ 


'c^l 


«p:^/J!^ 


'V 


Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


'% 


ft 


r 

O 

S  4^ 


y  « 


I 


I 


i 


202 


niSEANi:s  OF  Tin-:  hlood. 


f 


I"  • 


■ 

i 

; 

l^^^^w 

Hi' 

li 

HB 

L 

% 

.soooiidary  aiueniiii  .-^('cii  tlicrc.  Mai>v  cases  have  I)w'n  doscribod  in  this  cnuiitu 
and  t\v(Miry-i'i<j;lit  iiavc  come  nndcr*  my  iKTsonai  ohsorvatM)!).  Altlidii  J,  il',,, 
disease  sometimes ooeiirs  in  cliildren,  it  is  mneli  more  eomnKui  i,-  those  u\  ml 
die  a-re.  The  youngest  patient  I  liave  seen  was  a  girl  of  twenty,  hut  (iiUliti, 
\\i\y,  t'olleeted  some  ten  eases  in  patients  under  twelve  years  of  age.  ^[;llf .,  ;„., 
attaeked  more  ('re(|Uently  than  females. 

There  are,  assoeialed  with   certain  knov;n   conditions,  many    instaiicrs  ,,|' 
progressive  and  fatal  anicniia  which  cannot  be  distinguished  clinically  fioin  i|,, 
idiopathic  form  of  Addison.  Severe  aniemias  accompanying  pregnancv  ami  |,;,|. 
turition  make  up  a  large  proportion  of  the  reported  cases  of  pernicious  iuianii:, 
Again,  certain  atrophic  conditions  of  the  gistrie  mucous  memhrane  give  ij.,  tn 
an  auicmia  at  once  progressive  and  pernicious,  but  by  means  of  tl-.e  iin|)!'„v,.l 
techni(iue  for  the  investigation  of  the  gastric  contents  it  will  sometinus  l„.  ,„„. 
sible  to  exclude  these  intra  vitam.     Lastly,  the  grave  secondary  aujemias  mn-,- 
quent    upon  the  i)resence  of    intestinal    })arasites  (Anchylostoma   dii.M||.M,.||,, 
liothriocephahis    latiis)  may   be    extremely  difficult  to  recogni:<e    until   uim' 
death. 

In  eighteen  of  my  cases,  however,  there  was  absolutely  no  appreeiabli.  can., 
for  the  anicnn'a,  and  they  therefore  correspond  to  Addison's  description.    A-  \,i 
we  are  unable  to  say  definitely  whether  the  cause  of  these  obscure  ana'iniii.  i<i„ 
be  looked  for  in  a  luemolytic  process  or  in  a  detective  htemogenesis.      ,S((.|,|m 
Mackenzie,  F.  P.  Henry,  and   others  believe  that,  owing  to  some  (iuih  in  i| 
process  of  l)lood-niaking,  the  corpuscles  become  abnormally  vulneralilr,     Ti: 
weight  of  opinion,  however,  on  the  whole,  is  in  favor  of  an  increased  h-^w 

lysis.  ^   The  experiments  of   Quincke  and   Peter  with   regard    to  flic  >w  _  

BQous  increase  of  iron  in  the  liver,  and  those  of  Hunter  bearing  on  tlir  ,,x,|,.  |  "nl  noted 
tion  in  the  urine  of  ipiantities  of  j)athological   urobilin,  are  interesting  in  ti,i- 
connection. 

Birch-Hirschfeid  holds  that  the  tissue-destruction  and  the  retardation  nt 
blood-coagulation  favor  the  idea  of  a'l  infectious  origin.  Unfortmiately.  diir 
kn()wle(lg-e  of  the  etiology  is  as  yet  far  too  limited  to  enable  us  to  eoiisinirtMnv 
theory  which  is  wholly  adequate  or  satisiactory.  Only  by  the  most  caivHi!  tm\ 
minute  examination  after  death  of  patients  whose  blood  during  lit;,  ims  hn 
ctirefiilly  studied  according  to  modern  methods  can  we  hope  to  find  the  soliitimi 
of  the  proi)lem. 

Morbid  Anatomy.— The  pallor  of  the  whole  body  surface  and  ..f  tli>'  | 
organs  is  striking,  =.nd  a  characteristic  lemon-yellow  tint  of  the  skin  i^  piosciii 
in  many  cases.  As  a  rule,  the  body  is  not  emaciated,  and,  as  in  most  imivmia-, 
the  subcutaneous  fat  is  not  diminished.  The  muscles  may  be  pair.  l„it  aiv 
often  intensely  red.  Piinctiform  hiemorrhages  in  the  orgous  and  on  ilir  s ;  'i^ 
membranes  arc  (juite  common.  The  lungs  are  iK.t  particularly  abiinrniMl.  Tlio 
heart-muscle  is  very  pale,  light  yellow  in  color,  and  shows  in  fiv-li  tvn-A 
preparations  the  most  intense  fatty  degeneration.  The  walls  of  t!,.  sviitii.l:- 
are  remarkiibly  lax  and  flaccid,  and  the  cavities  ccmtain  light-eoloivd  IhA 
The  intiina  of  many  of  the  smaller  vessels  may  show  patches  of  lliDvdcuamr- 


alio'i.     'I'JK 
fiitty  degeui 
ivsiilliiig  fi 
iviTiii'ded  as 
and  liitty. 
■I'dii  ill   the 
il('|Hisited  in 
■|wiiiiens  a 
picture  from 
tlio  disease, 
A.  ('.  Scott  .- 
aiiiPiiiia. 

Xatm-ally 
Tlir  spleen  si 
iiiorciised.     T 
:lioy  were  of 
iias  also  been 
:iMiI  is  apparei 
Kimlflclseh  th 
and  Hiiidfleisc 
«iis  Mil  iiiabii 
imrniiil  iion-ni 
(Vrtalii  oth 
*^ii('li  are  the 
^rilks,  and   Bi 
■iini  noted   bv 
Symptoma 
li";iltliy  lieu'ins 
:illy  tlic  onset  if- 
alile  to  give  tlu 
'"'lies  paler,  an 
|iitatioii  of  the  I 
fill'  fill's  are  no| 
:i:';:nivatc(l,  and 
iliaractoristic  lei 
'iPl'i'tite  is  poor, 
ii'dcniiitoiis.  and 
Tlic  end  is  grapl 
till-  patient  can 
'alls  into  a  prosti 
to  the  very  last, 
'"'^'*  of  the  gene 
-trikinir  contrast 
I'ospppt." 


/'/^Or/A'y.Vv/r^^    /'/^A>A'/<70.x   AX.7,^fu. 


>(1  in  tliig  CMiiiiti'v.  B  ''""''■ 
II.     A]tli(iii:ii  i|„, 
1  i-  those  .11'  iiijil. 
onty,  hut  (Miiliti, 
:'  age,     Afiilr- aiv 


Tl 


K'  stofiiiicli  in  til 


tlitty  (loirc'iierativo  cl 


it»iij,n's  ill  tlio 


I""'<'ly  idiopatli 


'('  cases  is  t 


""'"•f  ''■'"".  ''•"■^'•'■"'f'  "t'-oi'I'V  of  the 


i'tl 


lornial 


e.\e( 


IH'  seeretinjr  tiihiil, 


iriiiiided  as  primary 


,111(1  liittv, 


TJ 


nnicosa  must  of 


■ptf 


iir 


203 


liiiht 


";  '>vor  i„  most  of  my  autop, 


't'  aiiji'uiia 


<'ours(.  |,(>  m,  lou.r, 


111  ill  tlie  liv 


"  «'•'•.«'■■  cases  it  ^^•as  enlarjr,,,].      'j^| 


»sio.s  was  iKiniial 


r 
in  si/0 


iUiy  instances  ,,|' 
■liiiically  tVnin  ||,, 
•egiiancy  ami  j,;,,'. 
LTiiicious  im,-i'!iii;„  Mm  tlii'  < 
hraiic  give  i>is,. ,,, 
of  tli(>  iiupnivc^l 
oinotime<  lie  pus. 
y  aiuemias  i;,u.,.. 
toiiia  (liiu(|(.|i;i|i.  ■  :iicivasof| 
jni/e    until   ;iit,T 


t'r  seems  f,,   I,,.  ,.) 


laractei-istie  of  tl 


l<1"'site(l  i„  tJ,o  outer  and  niiddl 

■p-xmions  appeanu.  to  outline  the  [.ii;:,;,.;,, 


zones  of  tin.  lol,,,], 


iiictiiro  from  that 


won  in  secondary  ana-n 


!arie; 


'o  pcn.liar  distribution  of  t| 
I'^'cs,  the  pigment  I 
0^  inid  in  two  of 


lese  ( 


le 


Tl 


ins  i> 


I'scaso.     The  liver  in  fortv-ti 


"'i>,  and  may  |„)ssil)lv  I 


K'ing 

my 

quite  a  ditreren't 


A.  ('.  Scott  sliowed  tl 


iis.s 


ve  consecutive  :iiit 


liiijpiiiia. 


'pccial  lesion  in  ik 


opsies  examined  f 


»t'  J>eculiar  to 


wi.ses  other  than  those 


or  me  hv 


•f  IK 


X.idi'-ally,  the  h.-cmopoiet 


pernieioi; 


The  spleen  sliows  no  charact  -istic 


'<•  organs  Jiave  been  tl 


ic  o 


Tl 


;lioy  were  of  a  rich  d 


yniph-glands  mav  1 


esioiis ;  the 


ibjects  of 


nnount  of  iron  in  it  is  usu 


Icep-red  color  reseml 


)('  nnclianged,  though  in  tl 


anxious  study, 
aliv 


IS  ai)I); 


illK 


ami  Kiiidfleisel 


ipprpciablr  cnn,, 
<<'ri|)tion.    A-\rt 
ire  aiia'iiiia<  i<  Im 
'iiesis.      Stcpli,.;,  B  "ii 
■^ome  tiinh  in  \h,-  ■  "'"'mal 
iiliieraiiic.     Tii- 
increased  Iiumhm-  ■  "^'"'l'  are 
I'd    to   the  ciinr- 
ng  on  the  (\\(iv- 
itcresting  in  tiii- 


iiiis  also  lieen  noted  by  Weigert.     Tl 


)l;ngspleen-tissne- 


'ii-co  of  mvc; 


ises 


iirenth 


Itlcisch  the  iiiai 


replaced  l)v  hji>mobl 


''0  amount  of  yellow 


'IStlC 


marrow 


I'ow  appeared  to  be. 


fd  marrow,     fn 


■a  condition  which 


IS  diminished 


one  h 


1  case  rej)orted  bv 


!'  's  inclined  to  think  that  tl 


1;*  an  inability  of  tl 

"on-nucleated  red  I.K,,,,! 
Certain  other  h 


10  cause  of  tlu 
<'  organism  to  ch,,ige  the  nucleated 


ii'J^o  mass  of  nucleated  red  e<.|I 
pernicious  ana>in 


■<''Ji'pi!S':les. 


i-od  cells  into  tl 


la 

iO 


tl 


■iinl  noted 


ions  Iiave  been  described,  but 
'<"  ;-'^=niges   in   the   sympathetic  gangl 

the  posto 


none  of  them  ar 


niivs,  ami   Rrigidi,:„„I  the  scl 


orosis  in 


!  nitardation  ni  ■  ^ili^' <l 

ifortiinatelv.  diir 

to  coiislnict  iiiiv 

ninsl  carctli!ii!ii| 

ing  life  lias  Ih'cii 

tiiul  the  soliitimi 


'»y   fiiclithcim. 

Symptomatology. A 

■■>^^h-  I'ogins  gradually  to  develop  the 

's  a  rule  it  i 


I  mentioned  by  (iueek 
nor  columns  oif  tl 


■0  constant. 


eft. 


lie  .s 


ipinal 


"  nuiivichial  wl 


10 


Por'  .ips  has  before  1 


onset  IS  rai)id,  but 


symptoms  of  an 


>oen  jierfectiv 


aliletogive  the  exact  date  of  the  I 


s  so  insidious  that  the 


aiiiemia.     Ocea,- 


lon- 


paticnt  is  scarceh 


"»'?■•<  pal.'r,  and  notices  that  I 


l/eginning- of  his  illness.     Ho  grad 


ration  of  tl 


10  licai't 


•otireseasily,  gets  out  of  breath,  ami  I 


l)C- 


tlii'  ears  are  not  niicoi 


oil  the  least  exertion.    *Head 


imon  as  earlv 


ache,  vert 


''irsrravated,  and  later  o.,  the  pall 


•^vniptonis.     All  th 


'^i<», 


and 


iialh 


las  ]j  ti- 


nuging  in 


face  and  of  tlii' 
L'  skill  is  prcsi'iii 
1  inosl  aiiii'inia-. 
)c  pair.  Imt  :i:v 
id  on  tlic  si ;  "i< 
abiiorniul.  Tlie 
ill   fiv-ji  tciHvl  I  '"'""^  <><'  tl 


'li'i^'teristic  lemon-ydlow  tint.     The  ,1 


I'""'"'  '"i>y  1)0  extreme,  the  si, 


ose  may  be  gradualh 


iPi"'ti(e  is  poor,  and  nan 


■."•estive 


in  assuming  the 


"'''•'">!'t'>'is,  and  hiemorrl 


if^oa  and  voniiti 


organs  become  disturbed,  tl 


Tl 

'tl 
fill 


"■  ^'"«l  's  graphieaily  described  bv  Add 


'=>.i.^os  may  take  place  into   tl 


"'■  patient  can   no  Ion 


into  a 


ler  rise  from  bed,  tl 


i«>n  :  "  The  debilitv  1 


iie 

lecome 

'o  mucous  membranes. 


"f?  are  fre(|ucnt.     The  ankles  1 


1.   Tlie  I  '"  t'"'  very  last,  and 


"•ostrate  and  half-torpid  state,  and  at"  I 


10  m:nd  occas 


afte 


'0  general   frame  and  t! 


r  a  sickness  of  several 


leiiirt! 


iH'comes  extreme, 
ionally  wanders;  he 


i^rn  expiivs;  neverthcl 


'ess. 


(I;r  v-ntnrl'.«  ■  ■^ti'il^'ing  contrast   to   the    fail 


-colored  hli«"l, 
pf  lii!!\-(l('::c'Md'- 


i'c«|)r<'f, 


Ul 


>o  amount  of  obesity  oft 


"'••nths'  duration,  the  bnlki- 


•0  and  exhaustion  observabl 


Thk   I5i,,,„n    EXA.MINATIOX. 


■on   present  a  m,)st 
!o   in   everv  other 


■Tl 


10  oligocytha?mia'is  al 


ways  <uarkcd,  and 


204 


J)Isi:asi:s  of  the  hlooik 


\f 


h 


f,  ! 


is'jrciicrally  extroino ;  in  one  «iso  reported  In-  (iiiineke  then-  weiv  ,,iiiv 
]4.">,()()()  red  eorpii.seles  to  tlie  eiibie  iiiilliiiietre  just  Ix'toro  deatli.  T|„, 
oligoeliromieiiiia  does  not  keep  pace  with  the  eell-rodiictioii,  the  peiv,  nra-v 
of  hienioglobin  always  being  iiiglier  i-ehitively  tliaii  the  percentage  ,,['  |,,1 
gh)bnles.  In  one  of  my  eases  tiie  hicniogiol)iii  percentage  was  greater  Irs  |ii 
per  cent.  This  relative  increase  in  tlie  indivifhial  globular  riciinrs-  j,  .n, 
iiui>ortant  point  in  the  differential  diagnosis  between  this  disease  and  elil,,r,,,i. 
as  well  as  the  se(!ondary  aiiieujias.  The  value  of  this  sign  was  first  noi<.,|  l,,. 
Laaehc,  anil   it  has  by  many  been  considered  path(jgnomonie  of  the  di-iasr. 

Via.  it. 


BLACK,  RED  C0RPU6CLE3 


RED,  HAEMOGLOBIN. 

liliKMl-cliiirt  (if  ('use  (■!■  IVriiiciiiiis     niciniii, 


BLUE,  COLORLESS  CORPUSCU! 


M!. 


While  we  acknowledge  and  appreciate  its  diagnostic  importance,  vrt  ui' hum 
warn  the  student  that  even  with  the  best  clinical  luenioirlohiimuc!!!'  >. 
Fleiseld's)  which  we  possess  the  <lcterniination  of  the  amount  of  i.ildiiii:.' 
matter  can  only  be  ai)pr()ximate.     Although   in  blood  which  is  iwAvh  iKH'iiia! 


Wood-corpiiseh 

known  as  niic 

J  wliicli  measure 

|«'ll.s(Fig.  10  (, 

[tlio  niiniher  of 

pliltrs  are  few 

'>ii('  tm-ns  w 

r<fiiiiic<l  specinici 

[tliat  the   large 

'''lii'licli,  liowevf 

I 'iiii'lcMted  red  hi, 

[■ ''lii^t,  which  isal 

["ImVIi  stains  int 

iviTv  large  t;,nn 

l)l;tsfs  „f  Khrlicj 

M"  the  iiiieleated 

-latter  to  tli,,,s, 

'•'i''  "i<'i;alub| 


liore   won    ..niv 
ro   (loatli.      Ill,, 

,      the      |UMV(1||;|M,, 

Tcciitaj-'c  uf  ,,„i 
as  givatiT  Irv  Id 
r  ricliiK.-s  i,  im 
sc  and  cIiLiom. 
;is  first  ikii.iI  !,.■ 
;  ot'  tlif  (lisiw. 


nor 


80/ 


70/ 


60? 


50;! 


lOi! 


COLORIUS  CORPUiCliS 

fc,  yet  we  iiiii-l 
lohiiiinu't!'!'  iV. 
lilt  of  ciildriiii; 
;  iicMi'lv  iKH'iual 


thp  rnor  jiiav  not  anioinit  to  m<...,.  *i        o 

I-e  ^l.own  tliat  wlu.n  o,  !   !.:      .t:  '  /'':^  '^'^"^•'  ^^"-^  and  Lot.ins' 

: -"^"  •>^-  ^"^  '-.->.'.•  -o:;  I't^lrrr  'z  ;'tr^^r  ='^  ''■ '-"  '-'■' 

«oiil.l  alway-s  bo  loft  nioro  o.-  L  i    d    i  t    sT  ^  ^.^7  '"  ^■"•^'  ^"^'^'  -'" 
Til.'  frosli   blood-siido  rovo'ils  ....„.,  . 

«.,-i,np.  ..„,  ,,„i,„i.„  „„:,:,  t;,  s  ':r  "•  "'""""•'•'"  "•"■«■  '^ 

l»-  '.v,K..»     They  ure  a  o„„„„,;,  fi'       .   :  ;;:'■'!" «  °''  "  ,"  -versio,,  ,„  „ 

<'■  <>'■■"  I.").-  size  wliici,  „.<,,„„„  fW  tl^r  "  "  "  ""W"""'  '» 

Mi»S"'.  I«..i..g  hi.,  „,,i„i„„  „„  ,  ,„„|'  '  ."'"'■^^  l'.™."gl..lm,-i„,.,-„Ko.     K,,,.. 

""■*  ™"'"°'  "^ '" ""  -«-''^>  -  '-■-•  ™«-he::  ::;;,:;r;;;:;,:^^^ 

Fro.  10. 


o, 

I  fioJ  rorpnsdos  from  a  case  of  profound  ana-mia      i    ,    k^^  , 

Hood-corpiiscles  are  maerocvtes.     Besides  tliP«.  ii 

""■  •"""I'or  of  lenooevtes  would  "ovn,  lofu-ooytosis ;  in.lood, 

"t '■-  ■' ".t.::!irt\;';i::;;r '"  "-'•'""'■  ^'^  "'"-- 

arh-,.|i.  l,„„,,.or  hn,  ,,„i„,„|          !                 reiativcly   am.cwhnt    i„cre,»o<i. 
'  i»-l.  wh;,.|,  is  al ,  ,1,^1;,     ,',,."'"  ■    ']  '"■  ""''""'■>■  '»"■>  » .i-nK.- 


<"y  la'u-  ii.nn,,  „i,h       J^  ft";  I''"™  V'""","™""'  '"  ""'  '■'"  i  ""'I  (2) 


;i*  ■■<■  ..:,„.,i..„).  ,P,.,.:;i,  ■;  :'-r  n , '  *  "■';?'""''"'»  -  '^'-'"■ 

I"", '"- ' -*■  «mb,v i,i:„«,j':j: :,,""""'  "■■'^"■" <'■*  y"^. 

""'  "">'"l"l>l!»!s  are  toiuKl  „i,|v  in  VITV  „„nll'  1 

'J        Mil  MMll  iiiiiiibois,  and  tlm,  ,i,„cli 

'"""H-  '*'■*'-.  ni,r|iH(,  188D. 


ill  1 


H  f 


I  'I 


206 


DISEASES   OE    TIIK    lilAHHt. 


r 


I 


if 


(Icp'iioratod,  in  tlip  isccoiulary  ima'inias  ;  in  pcriiicioiis  anajiiiia  and  in  ii:c  |:it,,r 
.stages  (.f  Icuka'niia  tlioy  arc  niinicroiis.  Ehriicli's  description  of  tlio  ii;ii;.n.|„ 
forms  of  defeneration  of  the  red  disks  will  he  foiuid  of  great  interest.  .M.^v 
particularly  we  wonlil  draw  attention  to  the  retrogressive  changes  i. mhI,,, 
in  specimens  stained  (lonl)ly  with  hajmatoxyliii  and  eosin. 

TiiK  Ciitcri-AToRV  Systkm.— The  important  symptoms  referal.h  i,,,],, 
eardio-vascidar  system  have  heen  already  mentioned,  of  which  the  di>!iossin.r 
palpitation  may  give  the  ])atient  most  concern.  On  physical  exaniinar,,!,' 
besides  the  loud  venous  hum  in  the  neck,  nnirnnn-s  may  always  1h  Ii,..,.,] 
over  the  cardiac  area.  There  may  he  visible  pulsation  and  throbi)in;.  of  ti„ 
larger  arteries,  and  in  two  of  my  cases  venous  pulsation  was  noted.  A  ,.;i|,i|. 
lary  pulse  is  frequently  to  be  seen,  and  a  sphygmographic  tracing  of  the  ..,,|. 
lapsing  pidse  may  be  quite  suggestive  of  aortic  insufficiency.  HieiMMnl,;,,,,. 
into  the  skin  and  mucous  memliranos  are  by  no  means  rare,  and  there  nmv  1« 
retinal  hiemorrhages,  causing  blindness  or  partial  limitation  of  the  visual  li,,],] 
An  ophthalmoscopic  examination  should  be  made  in  all  severe  cases  of  aiiirmii 

The  tendency  to  fatal  tin il)osis  spoken  of  in  connection  with  chl(,i(wi>  i, 

never  seen  in  ))ernicions  auicmia. 

Tmk  Kksi'[I!at(>i,-v  Systkm.— In  the  earlier  stages  dyspnrca  is  cniniiinnK 
present — a  symptom  which  later  may  be  much  aggravated,  even  to  Mich  an 
extent  that  the  breathing  becomes  stertorous  (amemic  dyspncwi).  Toward  tlie 
end  (edema  of  the  Iudl--^  and  dropsical  effusions  may  be  looked  for. 

Thi-:  DnJKsTivi,  Systkm.— The  lips  and  tongue  are  pale  ;  the  appctiic  i- 
variable,  but   is  generally  poor.      Dyspepsia,  nausea,  vomiting,  and  di;iriii..;i 
may  be  present  throughout  the  whole  coui'se.     The  liver,  as  a  rule,  is  of  wmwi 
size,  but  the  spleen  is  often  slightly  eidarged  and  its  border  at  times  |)aliiablr, 
The  urine  gives  evidence  of  decided  changes  in  tissue-uietaniorplKisis.  Tlie 
urea  and  uric  acid  are  increased.      A  low  specific  gravity  along  with  a  (link- 
colored   urine   is   more  c   less   characteristic.      Hunter  and  Mott,  wlm  li;m 
investigated  the  urine  chemically,  have  proved  this  to  be  due  to  the  piv-iii,, 
of  pathological  urobilin,  a  substance  differing  in  many  ways  from  (he  iii„l,||i,i 
found  in  normal  urine.      The  addition  to  the  urine  of  a  fi'w  drops  of  an  ;iir... 
holic  solution  of  zinc  chloride  gives  a  marked  green  fluorescence,  but  tli(<iil,- 
stance  is  best  detected  by  spectroscopic  examination.     If  pathological  iinil.ilin 
be  ]>resent,  a  well-marked  ;d)sorption-band  will   bo  visible   lying  vW,-  tn  tli. 
line  F  and   fading  off  toward  h,  With  a  considerable  absorption  of  the  diitir 
part  of  the  blue  si)ectrum.      rcptomu-ia  has  little  or  no  significaiKc. 

Fever  may  or  may  not  be  present.  Thus,  a  normal  tcmperatiiic  iiuiy  h. 
noted  for  weeks,  and  afterward  be  followed  by  an  irregular  pvivxia.  Tin 
increased  sensitiveness  of  certain  bones  (c.  y.  the  sternum)  to  pivsMiir  lia- 
probably  been  exaggerated.  With  the  "aiuemic  sclerosis"  of  the  coid  \\m 
are  in  some  cases  disturbances  of  .senvi.tion,  and  in  one  instance  ;iii  cxtcii- 
sive  paraly    •     .as  observed  by  Lepine, 

Diagnosis. — The  essential  points  to  be  noted  are— (1)  the  severe  irradcof 
oligocythicmia;  (2)  the  increased  mUnr  (jUAmkurv  ;  (,'})  the  presen.r  of  iniiiiv 


"'  ".relapsing  ji 
ill  which  the  in 
'"!-(■  rcpdi'ted  re( 
fitter  cure  by  nr.- 
Treatment.- 
"-is  ill  this  (li,«o 
flint  \vc  iiinst  nii 
iiiJiTiuiiially  inci 
''«'  i'iUieiit  will 
''fai'twith  ;!  mini 
tliei'ml  „f  the  (1, 


a  and  in  tin  |;,t,,r 
II  of  tlic  <i;ili.n.iii 
t  iiitoixsi.     .Mu", 

fliailfTCS      I.    v,.;,|,,| 

s  referahl.   i,,  ,1,,. 

'll    tllO     (li-lll.ssin:_r 

<'al  <'xiiiiiin,'ii;,iii, 
always  li-  li,,,,;.,! 
tlir()l)l)iiin'  ,,f  ilii 
noted.  A  caiiil. 
acinjjf  oi'  ihc  ,.„|. 
.  Hieni'iri'liii;,,., 
md  tliorc  iiiiiv  1, 
niic  visual  ti,,l,| 
cases  ()('  aiiii'iii;;i, 
with  elil(pni,si>  i« 

ICCa  is  (•nllllMiiiiiv 
L'VOn     to    .-llcll    ;||i 

a).     Toward  tlic 
i\  for. 

;  tlic  a|i|)('tit(h 
ir,  and  (liai'i'liu>;i 
"idc,  is  orii(iriii;il 
t  times  |ial|Kii)lr, 
morpliosis.   Tlic 
>iiff  with  a  (l;irk- 
Mott,  who  have 
to  the  |)i'('S('iiii' 
roiii  the  iiniliilin 
Irops  of  ail  iilcii- 
leo,  l)iit  the  sill, 
oli),i;iVal  urnliilii 
in^r  clii-c  t(i  till 
ion  ol"  the  mitiT  | 
iiidcaiirc. 
|ieraliirc  ninv  iw 
'  pyrexia,    Tlic 
to  pressure  h< 
'  the  cord  tlicrc 
tamv  an  I'Xtt'ii- 


„,aere,ytos   and    Ki^antuldusts ;  (4)  the   al.senee  of  nnv  ,..„■      r 

ana..nia;  (5)  oeeasionai  fehrii,.  distnrl.aneos  •  in        *'"•''"'";  '"''   •^••'••>"«la.T 

7,  l,a:norrhages,  ..artienlaHv  retind      S    /.^^^       '  •"""'"  "'"  "'"  ^''"  ■^'<''"  = 
rieney  of  troat.n.>nt.  '  '  ^^  ''  '""^^''^''^-^'v.'  course  and  the  ineth- 

j;:^;;;;:i:z:,r,:::;:';::/''^^^^ •^.^i^.n-the 

'•'-••<'  Kl<.b.dar  richness  in  h:!;;         ^     Zt^'  '"'  'TT.  ""-^  ^"" 

lol.Ia-ls.     .\frain,aswehaves.,i,l  iL    ,'." '""V'"'    "•••-•^•"«" 'd    Khrlieh's  .,•„,,„. 

:aaH..d.  The  .ii.,;.rentia;  dh^  ;•  ';:  ;f: •  :;;:';^  ■"  ^■'"••'•'f  i^  "."ver  ve., 
an-  ana.nda  n.ay  he  extren.eh-  dilli..,;,:  O  ,  !..  ''7"""'"  ''":'"^  "^"  — '- 
main  to  a  niock-ratc  anionnt  df  e...-*..;..*,   r  '      *'""''"''  '"   ""^"^t  "'•'^'-'■^ 

.:nVin  of  th,.  jrrave  secon.i     v     e  1  '         '       •""  l'"'  ^'""'•^'  •''"  *'''"  '''"><"I-      The 

■ahc.astri.-'^nneosa  Iv    ,:  :r  rr''T'^\'''^''^^'-^^^ 
i"i^-  •"■'•"'•<li"fJ  to  ,no.ler,;  ,ne,J,;„i.       'nl!''  1  "''    ''  '^"'"'"'"-  ^''"  ^f'"'"-''- 
lias  not  the  yellow  tint,  althon.d.  tho   ,..,f  "  /^""'  '"  "  ''"'*''  ^""'  '*"  ""'■^•"  <"'*'^ 
•-l-i-      Wl.cn.  into  tina    l'  j  "       '  '"='^  l"''-"^  ^he  si.ns  of  severe 

i-:.lly  >brthe  l-asitcs  or  thei.:  <^..;      Sc;     '  ^'^'^  —- '   .ni<T..scop- 

i"onnry  tnhercnlosis  or  renal  di^c^s'.  Jm  i  '.""""  *''""'*'^i"'''"f  ""  P""- 

"•-"■•'  '•""!-'"-  '>-'t  oven    he    i^C^.,,        ;'■'"■"■  ^    "  ^"■'•'""'^"•'  ''^-  ='  -ell- 

"'  '"--er  at  the  antopsv  Z:^::^^TTT  "'"'  ^""'•'"""^  ''"  ="^'^ 
.v..nled  dnri,,,  ,i,c.  as'  .„.  a,.,..,'     •  ^  '  ,     •"  ;^;^-  ~  -hieh   h.  has 

Pro.nosis.-The  p...^,.,.i,  ,.  ,  „,.;;;       ;^     --";  ^vpe. 
urv  arave.     Tn  to  a  short  fi.,,,.  .       .i      i-  '  "■"'  "''  "".ii''f  cxiu'ct, 

i::l^';;/i«??^;;'^::'=..:f;:;:,::;\;:;::^^ 

I  ^'M-.     Son.e  cases  appear  to  have  l,cen  e  .ti^e     .  T      ""  """"•'  '''""- 

of  the  atleetion,  at  least  for  ■,  tinu    I     ^      ^  ^         ,  '  "'"'  '"  '''''''>'  ^''"  l''''^'-^^-^ 
;  --  of  2H  eases.  2  ha^^:  r^  :    ij't:;;:'^^  Jl;  -'"''^^  •■•"■••'^-     ^  >'"  ^y  <-« 
^  -;■•!•  "'•  ^'"'  -i..-s  rcnaincd  in  con  :!     i  ^       ^  '^^Z}  !'  i''""   '"'"'  = 
='"'l'li^=>|'pcared  fron.  obsorvathm       R,l,n.,..   ./c/  ,      '"'  "  '''"■  .^■^■"•'^' 

I '■^"■"""■'>' <-•">'"">.  an.I  snch   •„,  occur    ''"  ,'""''''''   ""I'-'-vcnu.nt  are 
'  ^r..-.- ^.  •    .  •  •         '"•  '"•'•-"•'•cn,.c  ,s  so  <.haractoristic  that  Stephc.,, 


Mackenzie  in  his  recent  lectnres  n.al  .  i.  ;.  T'TT  1'"'  '^•'''''^'" 
;■<  ".-i^'l-ng  por„i,.ions  nn.tnia."  I  n  vs  1  ^l>  ?  "'''"  '"'  "'"^  ^'^'^^ 
'■■  "■'"••''  ;'"'  i-l.-ven.ont  was  .naintai:-  P  •  n  ^  'i  .r  ii;::''^  "\«  -'^ 
'"!>(•  reported  rccentiv  bv  Hale  Whifo  I...  •      •        ,  •""""''  '"'*  <"'•> 

after  enre  by  arsenie!  '"•''•'"''  -""''  '"■"'f''  f^'^"  ^'^von  years 

Treatment.-In  contradistin.'tion  to  the  b,M>..(i,.;..l     iv   *      e  • 
"■^'^  ■-'  tl.is  disease  tiio  .Irn,.  see.ns  to  1,     n  '       "^  "■""  '"  •■'''"'- 

^•'"'  ^ve  n.nst  n.ai.dv  rolv      It  n    v  •  '"".""  r^'"    '  "'"'  '^  '"^  ""  ="--'- 

-  .-Inally  i„...,,,,5,.,  j^,/  ,    "  ,    i^;)'^".  ^  ^'""  *--  <>f'  Fowler's  solution 

"'"  I""-"  -"  P>-ol>^>ly  do'.^        ,  r     ^^'T-*-"  ^^'  -t  well  bcrno, 


I'll 


2()S 


i)isK.\si':s  or  TiiK  m.oojK 


f 


%- 


the  patient  is  taiviiifj;  f'nim  '1\)  to  2")  iniiiiiiis  tliiicc  daily.  In  (tiic  of  iii>  i;i„,« 
which  rciiiaiiicd  well  iiir  three  yeai's  I  was  able  to  push  the  (iriijf  ii|ii,;;(i 
minims  at  a  dose.  Tlie  |)atieiits  oeea.sioiially  do  surprisingly  well,  and  (,  y_^,. 
offeet.s  from  the  drug  an;  unusual.  Some  }!crsons,  thoujih,  are  more  sum-  |,tl|,|p 
than  others,  and  as  soon  as  soineccdema  of  the  eyelids  or  digestive  (list m  i,,,,,. 
are    noted,  t!ic  administration  of  tlu^  drug  shoidd  be  discontinued  n 


;ii! 


such  symptctms   have   ilisappearcd,  and  then    resumed  at  the  dose  ;ii    .v],;,,! 
we  left  off. 

Rest  in  bed  is  essential  at  the  beginning  of  the  treatment,  A  li:^|||  I,, . 
nutritions  diet  is  highly  desirable,  tor  the  longer  the  digestive  powers  ||,,|,|  ,„,, 
the  greater  the  liope.  As  a  ride,  the  eases  are  l)est  treated  at  ln.me,  reini,v;i|  |,, 
the  .seaside  or  mountain  resorts  being  often  <lisappointing.  Hirch-IIiiv,||. 
feld '  recommends,  es|n'cially  in  the  early  stages,  a  residence  in  »i,||i, 
immune  place,  citing  Mimich  as  an  example.  A  systematic  massiinv  tii.;||. 
ment  is  often  of  great  ix'iielit.  The  use  of  rectal  injections  of  drieil  Mond  [ 
can  no  longer  advise.  In  the  later  stages  the  (piestion  of  blood-ti';in-tii.-.i(,|. 
arises:  it  is  of  doiibtl'id  advantage,  and  is  certainly  not  fre((  from  iLinnd', 
If  anything  be  ns(nl,  i  would  recommend  the  introduction  of  a  warm  plivsj,,. 
logical  salt  solution  into  the  subcutaneous  tissues,  but  even  this  can  at  lic-t^ivf 
onlv  tcmporarv  relief 

The  Secondary  An^smias. 

This  includes  all  those  eases  of  aiiiomia  resulting  from  luemorrliai;"  .imi 
those  coming  on  in  the  course  of  other  affections.  The  bhtod-impovcri-lniKut 
is  here  <hie  to  a  definite  cause,  and  the  eonscipient  anaemia  is,  as  a  rule,  dinrtlv 
proportionate  to  the  severity  of  the  primary  atfeetion.  Hut  whv  under  >iiiiil;ir 
comlitions,  with  apparently  the  same  etiological  factors  at  work,  the  iiiiii'ini;! 
in  one  case  may  be  slight  and  in  another   profound  is  difficult  to  cxnlMin, 

The  BhoiJ. — \o  matter  what  the  eatise,  the  blood  in  the  sviiiptiiiii;iric 
antcmias  pi-esents  certain  characteristics  which  arc  more  or  le.ss  constMiit.  Tin' 
degree  of  oligoeythiemia  may  vary  from  a  slight  diminution  in  the  iiniiiliiint' 
corpuscles  in  a  mild  case  to  an  enormous  decrease,  almost  as  great  a^  w.ikIi!  !» 
seen  in  a  case  of  |)ernicious  auiemia.  The  amoimt  of  luenioglobin  (Iicicmm's 
imri  pasm  with  the  number  of  red  blood-eorpuscles.  At  times  the  individinil 
globular  richness  may  be  below  ])ar,  but  there  is  never  an  in<'rea.-i'.  siirli  ;is 
occurs  in  perm'cious  auiemia.  The  mimber  of  white  blood-corpuscle^  isiihva\^ 
relatively,  and  generally  absolutely,  increased. 

The  fresh  blood-slide  varies  in  its  appearances  according  to  the  (lejriv.,MiN 
anaemia.  Tn  mild  cases  little  or  nothing  abnormal  may  be  noted,  while  in  tiiej 
severer  grades  one  will  find  as  marked  alterations  in  the  size  and  >lia|K' of  the) 
corpuscles  as  are  ever  seen  in  one  of  the  essential  aiiiemias.  ]\ricr(ievtos.  ni:i-l 
crocytes,  and  poikilocytes  in  such  a  case  will  be  mimerous.  In  staiiieil  >|Hvi 
mens  nucleated  red  blood-corpuscjos  can  always  be  found,  although  thpswnli 
may  bo  a  long  one  if  the  aiuemia  be  slight.     Tt  is  the  normobia-t  that  pi^j 

'  Vent.  med.  Woch.,  1892,  Apr.  1,  28. 


''  i>  >urpi'isin(i 

"■'"!'!  iiiiioimt  Ik 

l«1ilon'lij|(re  if  it  „ 

f"'  iii'tci'iai  pi-es,«ii; 
!'»'>  ill  tlie  tissues 
'""""•  "■iit'^iy,  an( 
["■'■''liiiliir  clement 

hM«w  (luring  thi 

VuL.  11.-14 


domiiiatoH  here  tl 


'SKrONDMiv   AN.I,^„,,s. 


tkf.vfralciicocvt 


'if^   'll<Wll(.l,|j,.s(,« 


•'■^iircaliiio.st  111 


«)ii«'''  'H  goiicniliy  prcsoi.t 


l)ci 

\\!IV 


N-lviM„.|,,„.„t.„t,.o,,|,ii,,,,     r,,, 


1)0  a  loi 


liii'iuiiirli 


ago. 


;  '«  most  iiiaik(^,|  i„  tl 


Anv 


Classifk 
arrangomciit  o/ 


ATioN  OK  Till.;  Si 


(] 


,.iNi.i-lact(.py,  J.avi,,^.  |„,,,„  ,,,, 


'<•  secondary  aiia<ii 


"'  i'liu'iuia   fl.llow 


•"•^■"■\in-    AN.KMfA.. 


209 

!'<■<•<  yt().si.Sj 
i«  iiicrcaso, 
iiig  a  M'vcre 


ni 


4  s(C(Mi(lary  aiiiuiiiia,  i( 
l"f ''"  «'"^"'  ''«^"t«  presclt  nm"| 
Tl 


"•■<v.s.sity  l,a.s,,J  o„  t| 


"'■"■'^  '"f"^"'««>pshas,ln,.sf|„.l 


'•y  «'ftc"   Ih>  (liHinilt  t.,  ,1 


I  ifl: 


'avc  Ik'cii  n 


l<'«''<l«'  wiiicli  on,,  of 


»ivcn  a 


)OOI1 

('a,s(! 


M'vcri 


'<■  most  iriiportant 


1.   \SMM 


i-\    I'ltoM   If.,, 


gi'onps  arc- 


^Po'.sil.lc  for  the  bIoo.l-in.|,o;. 


,  ■';'  ■■'  "■'"•"  •"  a  large  vessel    t 


''::"""!'"^-Tl.e  loss  on.l, 


hri.m  |iost-j)artnni   hie. 


liildT  o: 


til 


stoinaeli  or  tinode 


'il"ig,  or  til,., 


'■•""   "'.)i"-y  or  iroiu 


'<^'  niav 


''iil>t(ire  of 


'<"!  iiiav  l)c  til 


le  rcMi 


It 


lai'eal  varices,  and   in  v 


""»i,or  in  cirri 


l)c  severe   | 


"II  anenrisn 


!ia'niori'|iajr(.  j,, 


1  or 


i:fi»i»iTliages  we  mean  f| 


■"■""•«  "tlior  cndit 


ion>' 


|rli;ij;ic  diatliesi 


''•■^•'  "'•'•nrrinjr  in  individna'l; 


f'<'-i.s  of  tlic  liv.T  from  tl 

I'c  so-called  sjM.ntan, 


\W  tl 


eases   of 
le  (I'soph. 


Intakes  place.  ,pn'eklv  tl 


!/•  "1  {)iirpni 


'.  scnrvy,  and  h 


S  Sllflf.n|,,r  f 


If;  ii-oni  a  lueni 


'Oils 

lor- 


inic  (ili";einia. 


T\ 


";"'••-'  /'^  <•'  <li.nin„tion  of  all  tl.,.  i 


'::""';'"■''■"•  ^vi,crc,iH.i.K,,,d 


m  wiK 


'<'  f"fal  volume  of  |,|„od 


>lood 


'•""'■terial  tension  so  lonercltl 


III 


''oiistitii,.nts 


"""•<■  siHlden  and  profuse  the  loss  tl 


'at  death  result, 


ay  1.0  .so  n.u,.h  diminish,.,!  un,| 


s  111  a  ti 


lt;il, 


l'«' rapid  .shechling  of  th 


fie  <>■ 


'••cater  the  d, 


<'U'  moments,  and 


'""ioea.se  which  f 


•^''"  "'■  four  pounds  of  hl,„„i 


i"',i;or  of  /lital 


SVIICO 


-aw  seven  and  a  half 


would 


prohablv  I 


'pe. 


)e 


V  mnoimt,  cs,-aped    into  the  nleu,-.    '    "  '""'"''  "^"  '''"'"'•  ""  ^..-u- 

;"-''-"'  -''-  there  are  fW.  !       ^     I^l^:'''^'  '"' ;';'  ;--"-"..     On  til 

"■  'f  "".'^   "'^""atoly  roc-over.       Thus  '  "  "'='^'  ""'''I^^'  '""'  vot 

,„„,„n,,,„d  in  one  week  fn.ii.  '.■.;,''"  '^"•;""  "■'"-' to  lose  over  ..n 
^""7"-^  -  ".ay  he  nnahle  .^  .  , /'::';":':'"'^^  -^'-^  -.-"nl.ing. 
'■^  "'   •■"temrrhagia    fr,>ni    the    „.,  'P'  "^  '"'^'"•''■''I'age,  as   h, 

"^  or  ironi  cirrhosis  of  the  ^^      U^T'""  .  •^"•"'"""'••-    '-H'n^chal 

;-  '"H-  in  the  ..ases  of  female  pl^      ::""'•  '  ''  '-">'^-  -  -thhehl, 
^"'•'•I'agm.  ''''''^"^'^  Mifienng  from  hhvdin^r  pi|,,,  ,,; 

-i';.-m;r'h',;:  'Sinr::!;!;;!:.:?^:^'^""-;'^-*'  "-<-- ti. 

"""•'•I'l'fTo  if  it  oc,.„,  ;,.  ,  previous          1  "   '  "•■•:';  •"•  ^-  ''^'vs  aft,...  the 
'"''"™'  '"—  I--.nit    the  ^W    ^''Vr'"'"'"'''-     '^^'-  '«-orin,,; 
vl'ilo  the  h..emn....i :     ' ...  '•""'*''*'  P<"r.va.scnlar 


Imcv 


I  \V!it(.iT,  and  ,sal 


1110  constituent 


lorrhage  is  still 


'7''"'-  '■'^■'"onts,  an.l  it  niav  1 


''M^  irxCtnUo  ad  hh 

^N-<w^thisrc^,ie..tioi;;;:ith;; 


V>-'<^n.     The  ,.,.st 


s  are  mueh 
'o  ov(>ii   M-eel, 


gonijr  on.      The  all 


KS     Ol' 


'iioro  (pii,.h}y  ,.,.„e„.e<|  tl 


)ii- 


oratioti  of  (h,.  j 


"loiiths   hefhr,.  tl; 


lan 


oro  is  a 


"o  eurj.u,s,.ulai.  ,|ev,.| 


'"i'"'<>glohin  ,hjes  not 


lopn.eiit. 


210 


i)ish.\si:s  oi'  Tin:  iu.ood. 


2.  An-kmia   KiioM   Inanition. —  Here  the  plnsma,  as  a  nilo,  sudc j,, 

than  tlic  (lorpiist'lfs  ;  the  latter  may  Ih>  pt'osciit  in  aliiiust  iiorinal  iiiin  1. 1,, 
tlic  riihic  inilliiiu'trt'.  Tlic  iiiaiiition  may  Ix"  diic  citlicr  tu  a  (IcticiciicN  ,11  ||,. 
l'(t(Hl-sii|)|)ly  (ir  to  (listiirl)aii('('s  (»("  one  or  iiiDrc  of  llic  variinis  |iliy,-.iM|.ii;i|..,| 
processes  by  wliieli  digestion  and  al)soi'ptioM  are  carried  on.  (iood  cv  niiili, 
of  tliis  form  of  ana-mia  are  seen  ii1  <'aiicer  of  the  (csopliajjns  or  pylori^  riH  , 
and  In  llie  cliionic  dyspepsias,  especially  in  llio>e  ihw  to  atrophy  of  tli'  -umi  . 
mn<'ons  ineini)rane. 

.'J.  \  prolonjred  drain  on  tiie  all)innint)ns  materials  of  the  Mood,  n<.  uijiiii, 
what  the  canse,  is  accoiintahle  for  a  'arge  <;ronp  of  cases  of  ana'nii.i.  Tin 
lilood-im|toverishment  of  l?ri<;ht's  disease,  of  chronic  su|)pnration,  uf  in',,. 
loni;ed   lactation,  etc.  may  he  i'xplained  in  this  way. 

\.  Toxic  An.k.mia. — ITnih'r  this  lieadin<f  may  he  tahiilated  the  iiimin i,,, 
resnltinj;  from  varions  ])oisons,  orj;anie  as  well  as  inori^anic.  The  iiilliniin 
of  lead,  arsenic,  mercury,  and  |)hosphorns  as  hlood-^Iolmle  destroyer^  js  \\i|| 
known.  Of  the  infections  diseases,  tni)ercnlosis,  sy|)hilis,  and  nialiiriii  mv 
most  fre(|nently  associated  with  ana>mia.  In  malarial  hlood  one  inuv  wiiiiji 
the  corpuscles  jj;row  pale  nndcr  the  ai'tioii  of  tiu'  plasmodial  parasite.  A  |in.;. 
typhoid  ana'inia  is  not  nncommon,and  in  some  cases  the  jrrade  may  1m'  mvh  . 
In  these  toxanuMiiias  the  red  hlood-corpnscles  may  1h' directly  deslruvcd  .i^  in 
malaria,  or  the  ordinary  rate  of  their  consumption  may  he  inereaxil, 

The  aiuemia  aecompanyinfi;  pyrexia  is  (hie  partly  to  the  direct  actinn  of  ij, 
poison  prodncinjr  the  fever  on  the  Mood  itself,  partly,  perhap>,  to  mphh  iiii.|. 
ference  with   the  workint;'  of  the  hiomopoiclic  origans. 

Treatment. — ( )l)vionsly,  the  first  indication  in  the  treatment  will  li.tnr 
the  removal  of  the  canse.  In  the  secondary  aniemias,  as  in  other  seciiiiilar 
atlections,  this  is  nnf()rtnnately  too  often  im[)ossil)le.  .\  careful  |iliv-ir;i! 
examination  of  the  or<j;ans  and  ,:\i  examination  of  the  jriistrie  jnii'c.  >|iiimiii, 
urine,  and  fieces  by  modern  methods  will  often  reveal  the  primarv  rnusc,  It 
mij>ht  .seem  iinneecs.sarv  to  speak  of  this  were  it  not  well  knoun  ilmi  tin 
aiiiomia  aceompanyinii  malaria  has  been  treated  with  iron  before  anv  iiit(iii|ii 
was  niaile  to  kill  off  the  swarms  of  plasmodia  which  were  the  ;ictive  ctiiisi  .1 
the  blood-deirencration.  In  every  case  strict  attention  nuist  he  ^ivci)  totii' 
dietetic  and  hyiiieiiio  management,  a  part  of  the  treatment  fnlly  a~  iiii|i()ii;i;ii 
as  the  administration  of  drugs.  The  blood  in  the  antemia  followiiitr  .■«ii>liliii 
liaMnorrhage  in  individnals  jtrevionsly  healthy  may  be  restored  wiili  ;i>tiiiii-li- 
ing  rapidity,  and  often  without  any  medicine. 

Ft  is  generally  best  to  begin  by  confining  the  patient  to  bed.  Fur  tiii' 
aiiiLMnia,  apart  from  the  treatment  of  the  primary  canse,  iron  is  the  lust  dni;. 
The  particular  fljrm  chosen  must  depend  in  each  case  to  a  great  cMi  tit  on  tin 
idiosyncrasies  of  the  ])atient  and  the  condition  of  the  alimenttn-y  li:iii.  In  in- 
far  the  greater  number  of  cases  HIand's  pills  wore  fonnd  to  be  pcrllrtly  ^ali- 
factory,  thotigh  some  patients  do  better  on  the  officinal  tincture  .4'  the  [nr- 
chloride.  Jaiufway  prefi'rs  the  tartrate  of  iron  and  potassiniii.  lnit  iktIiuii- 
it  may  be  necessary  to  .search  still  further  before  the  preparation  .i|i|»r(i|iri;iie 


I'm  •-ides  tl 

miiiiy  (iinditi 

Tlii'sc  lion-le 

;b  li'iicdcyto," 

lcii('(H'ytosi.s  ( 

Iciicocytosis  1 

iiKiiiia.     Ife 

lied  t"  the  1) 

litifjite,  and,  ; 

these  cells,  it 

'.'iviifcr  ninnh 

till'  lilund  in  t 

;H'iit('  siippnra 

.Milch   ligli 

t\i>t('iice  of  cl 

Ikt  (pf  leiicix' 

Iiifirc  aliscess,  I 

iiiii<'li  as  in  id 

\\w  ninnher  o 

iiicyfi's  at  the 

"I'lriiDs  arc  ca| 

w'tivity.     The 

tniiii  these  ca.sc 

iiitii'ciy  (if  poh 

■'^pcaiviiig  g( 

imt  there  will  I 

prorKiuneed  locj 

tiim  in  a  certai 

iiimasc  in  the 

tlii>  (itlicr  hand, 

'lit'  ji'ciirral  pro 

.It   !lll. 

The  Incaj  )•(.; 

Tlii'i'c  Mi'c,  as  \\ 
"tilers  wliicji  ro| 
I'l'  rcs|)(.clivclv 
iiiitiire  we  as  ycj 
pi'iKliicts  cliisclv 
"f  cpi'taiii  tissue- 
ti'"iMliiit  the  pr 


'/'// /;    I. /; I  ('()v\ 'TOSES. 


•Ulo,  SllfVc      li,„|.,, 

I'lllill  lllllll  "IV  I,, 
(l('tici('nr\    II  il,, 

•IIS  |iliy.-i.i|.ij;i|.j|| 
<><"•<!    <'\;iiii|i||., 

ir  pylorii    .rili,.,., 

iliy  (tf  ill'  's\-\\-v 

l)l(IO(l,    III.    |||;,11,,|. 

)t'  illliflili;i.      Tlic 

iiratioii,  ..f  |i|n. 

Itcfl  tlic  ;ili:ciii;:i, 

TIh'     inilllcillr 

Icstniycr-  i>  \\,\\ 
and   niiil.'ii'iti  mv 

(tllC     IllaV    «;|Iri, 

arasitc.     A  |in.:. 
Ic  may  In'  MVrn. 

y  (ll'stl'nycil  ,i»  ill 

iiicrca-i'd. 
■cct  aniciii  di'  li,,. 
».-,  t(i  M.iiii'  iiiiir- 

nicilt  W  ill  lie  till' 
(it  her  S(rii|ii|;ii' 
farc't'iil  |i]n«ir;il 
ic  jiiici'.  sjiiitiiiN. 
iinary  c-iiisc.  It 
Iviiiiwii  llini  till' 
fore  any  alti'iiipi 
'  active  ciiiiN  .|' 

l)C   L;i\rll  tDlili 

illy  a-  iin|pori;i;it  I 

ollltwillii    >inllldl 

'd  willi  a-tiiiii-!i- 


2\\ 


Mil"   '"ISO  in   liarid   will   |„.    (;,„„,| 

•limiL'-  will  ...n.Hi.ucs  ,,n,v,.  cnici,.nt.     Still,  wl,,, 

iiiii-t  lall  hack  on  arsenic. 


riic  ^waters  ..(•  (lu.   vari.,„s  cl.alyhcatc 


The  Leucocytoses. 


'-^:'™-tx:::;:;;::;;r;^^^^^^^  -""■ 

n..- -ihii-,,., |„,,^„,,, ,i„„. „„, ,i„„   . i.' , ," " '  '''";■•' '» ""■■■■■^'-i- 

l.iB.-vM.«i»  „Tnm.,..  „r(,.r  „,™l,  ,,„|  i„  ■',  ,''      l'l'>--<i.il.«i.,ir' 

'■ ■.■'■-  "^i"".i"« ...  ac,:;,;,,,,:^  I;::- .;:;:, :: ;, Y""  " 

»■»•  ,"■•  ■■^■piai .1,,.  i.i„.,„„.„ „  s„, ,,,  '',■,'■  r ; ' '■ 

lilin.l..,m>.l,„,ll„.  „,,v„,,  „,.,,,  ,  '    "■ "- '"I  "'""■'l  llicn  l„  |„„. 

1.1 1 „„.... V,,,  li," :  I "'''''r '"■"■'■" '""■'■  *"""' 

.i;;:ll't.,;;:„":;;!;r  ';•;::;  - -'  t  '; » ■->■  ••'■  ".^ 

u  „f  I, ,„.s  wi,i,.i    r,i,„     ■ ':""'.' "  ""■  "■""" ' '- 

::m-;x::z!;::;;;i;:: - -no,,,,  j.,.„„„;r ,;;;',!;:;;;:; 

^|"':ikin.r  generally,  wo  aro  al)I(>  to  -nuss  :.,  .„,..  .„.„.„    i-  ,     , 

"'"  f''-"  "ill  be  a  IcMocvt.M-s      If  tlw    ,  i  ?  •'^•"'^/l>«easo  whether  „r 

l"--->uvd  lo..al  reaction--    ;:.  di  1-  "  T  '"   "''"''  ^'""•''  ''^  '^ 

"-'  in  a  certain  m,^  ^f  tl  "/i  'T''''''*'  ""'''  '""-"""t.'ry  exuda- 


^li 


•212 


/>/.%'/;, I. v/.'s   oy  77/a;  ni.<nn>. 


tivtly  clit'iiKitaL'tic!,  ami   lliul    llic  |>n'-('iicc  nC  dead   hactrriii  siitlicos  to  ;   .(,111" 
tor  till'  attnu'titui  of  tla-  IfiKtifvli's  (|{iimti).     'I'liis  (loc."*  not,  liowoviT,  1    iihiii, 
the  flicmntaxis  nsiiltiiiij;  tVoiii  tlic  iiijrciioii  of  -.nltstaii(<'<  like  tiir|H'iiii  1  ,  n,, 
that  wliicli   taki'ii  |ilarr  alxml  n  riaiii    nccroiir   iii'<':i-<  in   the  li\'i'r  an«l  i .  hiiiIi. 
^Iinals  which  havi!  Iwcii  shown  to  hear  no  ciiicct   rriation  to  niii  to-oi-h  rj^m. 
The  Miibjcct,  liowcvcr,  in  too  wi<lt'   to  aihnit   of  a  full  <liH('n.s>*ion  Ikm,     \\, 
vonld  cniphasizc  the  fact  that  lcncocv(osi>  occnis,  as  a  rule,  only  in  'ii-cii., 
which  have  a   local  reaction,  and   that  its  extent   is  |»io|)oi'lii:nat<'  to  tin    hut,. 
so  that  wc  arc  ahic  to  say  a  jtrinfi  in  a  e;iven  infections  diseax-  wlietli.     ,,|   ,, 
a  Icncocytosis  will  exist.     Tims  in  a  croii|ions  pnennionia  or  in  a  sn|i|iiiiiiii\. 
pleiM'isy  there  will  he  a  leneocyto>is  |)ro|iortionatc  to  the  extent  of  the  liiii._'  ,r 
pleura  involved,  while  in  typhoid  H'vcr  or  malaria,  >vliefe  there  is  no  iiiinknl 
local   reaction,  there  will  he  little  or  no  lencocytnsis.      Indeed,  in  t\|ilii)i(|  tin 
nninher  of  leiieocvtes  would  appear  to  lie  diminished.     This  pecidiar  clini;!,. 
tcr  of  the  hlood  in  typhoid  fever  l'nrni>hcs  lis  with  a  ready  method  n\'  di-inv. 
vviw^  coinplications    in   that  disea-e.      I   have  often  in  my  own   wards  sim  ^ 
Iciieocytosis  appear  precisely  at  the  onset  of  a  complicating  pleurisy  or  pinn. 
nionia  in  the  course  of  typhoid  lover. 

The   course  of    the    leiicoeytosi;-    in    pMennionia    is    extremely    iiit(iv«tiit". 
lucreasinj:;  with  the   liiiijr-coiisolidation,    it    reaches  its  niaxiinum  jii-l  liiinr, 
the  crisis,  and  then   the  decrease  in   the  mi  ml  )er  of  leucocytes  is  as  iii.irkiil  ;, 
the  fall   in  temperature.     Thus,  a  lencocytosis  of  20,000  to  ."jOjOOd  iiia\  ilinn 
within  a  few  hours  to  (5000  or  SOOO.     There  is  some  reason  for  hi'lieviii;!' tli;it| 
the  jfivater   the  de;;ree   of  local    reaction    (of  which   the   leueoeyto>is  nmv  Ik;] 
rcfiarded  as  an  index)  in  a  disease  like  acute  lobar  pneumonia,  the  less  i.  dio 
virulence  of  the  ffeneral  l)lood-j)oisonin<;.     Thus  Tsohistovitch  claim-  ilmt  ii 
a   pneumonia   where  the  leiieocytosis   is   sliii'ht    or   absent   the   teniiiiiiiiiini  i 
always  fatal.     The  theory  has  received  some  support  from  von  Jjiksi'h ;  ;iiii 
if  these  results  are  coiilirmed,  the  blood-examination  in  pneumonia  will  bin 
grciit  use   tiir  the  prpjiiiosis.      In  one  of  my  own  cases,  however,  tliciv  un- 
leiieocytosis  of  over  45,000  to  the  cubic  millimetre  just  beflire  dcatli,  tli 
autopsy  showinfx  a   croupous    pneumonia  of  the   ri<.dit  upper  lol)c,  tiijrotlii 
with    a  fibriiio-puriilcnt  pericarditis,    with    myriads  of   the   lanceolate  piuii 
mococci  in  the  exndatc.      In  a  recent  fatal  case  there  was  a  leuc(M\tii«i<  „\ 
114,000  to  the  cubic  millimetre.     The  disappearanoe  of  the  IcuciMytosi-  i 
erysipelas  is,  as  in  pneumonia,  also  by  crisis. 

In  addition  to  these  iutlammatory  leiicocytoses,  a  large,  sonietimc-  iiioniMii^flMnnjr,.a|    Ivninl 
increase  of  the  leneocytes  has  been   observed   in  the  cachexias  of   nialiiriKiiiH'"""'"^ 
neoplasms.     How  far   this  hnicocytosis   is  dependent  on  the  InenI  icactinni 
the  neighborhood  of  the  tumor  (necrosis  and  wandering-in  of  li  indcvtc-) 
not  as  vet  clear. 


ivitli  alterati 

iiikI  l)one-nii 

History  - 

lo  priority  In 

nan  I  lie   (iis( 

"riiiial  leati 

\rUf\i'  appear 

'rai-lc  had  d 

'iiMl  llie  peciil 

iiyly  spoke  0/ 

111  I'iorry  .-ind 

|ivii'iiiic  condit 

lili'.     In  I  Mo  I 

rvilia'iiiia  to  ill 

Jimilliiiri'jipj,   ,j 

ilii'allirtion — . 

•'r«  (if  Kdiiibi 

\'iii|i()\v  d,, 

III  states  that  h 

lii'|ii'('seiiee  (if 

I'Citlicr  with  ni 

Ki-iN  where  thr 

li'i'iiis  that  were  j 

"""ii-^  foi'iu  in  w 

'«•  Ik'i'ii  custom 

nii:i-,  it  is  rare  t( 

ill'' twit  latter.     ; 

M'lirdcd  (f.eidx' 

inilt|ii'iMleiitly  of 

liinii  is,  Iiii\v(>ver, 

™lly,;iii(l  there  w 

'"I'l'^nwd  headiiif 

'iiliicr  reportcc 

|fp.'initiis  of  the 

iilmtic  eiemonl 
Ipvi'tlic  name  Ivn 


iis  we  sh; 


Definition. — A  peculiar  disease,  assuming  various  forms,  elKinu'trrizcil  1 
a  persistent  increase  in  the  number  of  the  white  blood-corpuscle-,  associiitd 


\  'listiiietion  b 
"'"""'•  is  iiMiel,    1,,, 

Etiology. —X^t 
'!">^i«i!  and  JMctcri 
"'^'l'^^a.^Msalnios 
1'^'  l"ika-rr.ia  is  a 


II'IK.KMIA, 


iiU'k'OS  to  ; ,„||,. 

hoWCVtT,  (   .|)|j,i,| 

(■  liirpciilli  ,  III, 
ivcr  iiml  l.|ii|,!|. 
inicni-or  i.m, 
ssidii   li(i..     \\, 

only  in  Mix';!., 
ate  III  tli>'  hilt,,. 
I'  wlirlln  I  ,,)'  ||,., 
ill  a  sii|ij.iira,i^ 
it  iif  tile  hiji^r  ,,r| 
iTf  is  nil  iiii,r|„,| 
1,  ill  lyi'liiiiij  til, 

|M'ciiliar  i|i;ii:i,. 

Il'tllllll    III'    lliiCnl, 

ill    \V!iril>    sirii  ;i| 

)lt'iirif._v  up  jiiiiii. 


'ntlinlh.rnh'oiis.Mviimiiir,.;,!,,..    •      i  "'"' 

'  '—I • - '  ""«'•  ■■'■  '■«'"■'-  "■  "..■  -|. Iv„,,,,.„| ,, 

History  of  t.h«  A  «.._^i_  ' 


i«tory  of  tho  Am.ction 


1  |>i  iDi'iU'  lia^   I 
I"'   Hrsf   \ 


n;b    I 


"•••"     """ll    'lisjM,(,,i 


and  its  Different  Porm«. 


<>    !•(■( 


-..Miiiil  (i'ainiv  ,,/•  (I,,., I 
ii'irli'  ii).|M'aivi|  in  \ 


••V"i/..   II...  inci 


1'   l>  llnw  (i( 


Mciallv 


■'I'llnlljrl,    ,|„,    ,,| 


iscasc 


M 


va>c   in   tl 
•'^'11V(.  it  tl 


I'riii-ic  liad  (l<.s,.rilH.,| 


"VcnilMT,    iHir,;    ,•„(,,,,„, 


'•■    "liilc    |,|,„„| 

K'  name  Icnl 


'•'■••"I   tlial  \'i,,.| 


iiiii 

lluw 


•"•"rpiiscic. 


icrol'tl 


i<ii'Miia. 


\'iivl 


iIniI  1 1 


"'  |«-''lllla.    I)lnn(i-,,„„| 


'  ••"-'"  'I..'  EiU.lnnyh  J/,,,/, 


l|C 


'■!>  an 
liKw's 


;iv>|M»ki'  of  it  as 
kI  KoI 


itiiii 


'  \^iis  (Inc  to  tl 


'V//    ./, 


'_""■  vcar  IScnnctt  and 
■'A  l>iit  tlioii..|it 


uin 


In  rnnTv  at 


Ipvifiiiii'  t'oiiditiun. 

!|ilr. 


"■^"l'l""alionorilM,  |,|,„„,.     oti 
KXi'MsKy,  u|,„  ,|,„   ,„,,.. ^.^,^1   ^j 


"•;;';••'-■'"■••  "•'•pMs.  and  a..,.,.;! 


"•'■  '"'^«>  li.'id  1)(.(.„  „| 


III  l«r,i,  I 

lifiiiia  to  tlic  (lis,..,. 


"«'•■'  ''i'  IN-I!)uas  the  ( 
•;:""*■"  ^•""'■••"•"l  additional 


lat    I 


'served 


ii'sf  to  diair 


"'.^'  \V'Tc  .Iralinir  wit  I 


"Kiio-^f  flic  di 


I  a 


"""";«'-'pl' on  fli..  siil,j,.,.t,  ,.| 


ill  Ui(.  tiill 


nwiiii.-  vcar  til 


"iscs,  and  jrjivc  tl 


~'"is(.  diiriiiir 


iitli'ction 


I    paper  wliieli 


""""J,^  <i'r  liiniself 


"'  "fii'ie  of  I,.,,,,, 
"""i'i"i(lioritypnl,|is|,ed 


rs  of  Kdinl)iir-I,  and   iJerl 


ii'oiised  a  livel 


pi'iority  ill,  til,.  ,1 


\'iiv| 


"•\v  des,.ril„.,|   t\v„   ( 


III. 


y  <o,itrov(.rsv  l„.twei.n  tl 


iseoverv  of 
H'  pro/i.,s. 


was  a 


nely   iiiti'r(stiii;,Bli.  -tmes  that  Ik 
iniini  jii-t  liit;.|vHtlii|)r('seiK.(' of  a  lar<>- 
is  as  mark,,]  :,Bi..Ttli.-r  with  inarke,?  i„vi,i 

'0,01  Ml  y  (lr„|iH«Ns,  when,  the  spleen 

or  lielieviiij.'  tli;itHl"i'»is  that  \\ 

ocytosis  may  Inj^*'"" ''""in  in  which  the   1 


'i»niis  ,,f  the  (lis 


\w  to  rec 


■cas(.. 


■"i^'"'z<'  oi hiss  of 


fn  h 


IS 


( Hluhr  Pntlml 


:''.'"""'"•'• -niie  smaller  fi 


case; 


ii^*  chaiaet 


^■••""•"f  ..*•  ti.e  lyniph-dand 


"■'lis  of  leiieoevt,' 


eri/i'd  hv 


was  inn. 


verejiredoininaiit.      M 


<'i)iar<r,.(l    it 


my  years  lat(.r  .\ 


III  aiioti 


'"  the  M,,od. 


"•'^  fl'«-  larjrer  white  |,|,„.,|;„ 


ia,  the  li>s  i>  tln'H'Ki'-  I 


■ll  claiiii-  that  iij 
G  toriiiiiiiitiiin  ijj 
.'Oil  .lakscli ;  aid 
iioiiia  will  Ijc 
'ver,  thi'i'c  u;i- 
lefoi'c  liratli.  tli( 
M"    lot II',    tni^otlii'l 
ianceiilati'  \\\\m 

I    I('lli'iir\tihii 
..    lellnirvlosi"  ill 

ctiiiic-  I'Miirninii^ 
lis  of    inaliirii 
liical  iviirtiiiji  i^ 
ot'  iiiiroi'Vto) 


eharacfpi'i/f'ii  hi 
iisi'lc-,  ussociaw 


'«'ii  oiistonijiry  t 
it  i-'  rare  to  tind 


'"''^'-'"ill-row  sliow(.d  niarhed  <■! 


••"liiailll(h.seril,e(| 


'"'I'  .series  of 
■II 


"  •^P'^='l<    "f  lyniphatie,  sol 


anire, 


''"■'"■" '"'f<'''.     .Sofiir,  onl 


i'  piii'e  tiiriii  ,,f 


•|''<'iiie.  and  mvel 


.\ll 


ii  iiiyelojr- 
lioiiul,  it 


any  one  of  tl 


iMnrilcd  ( 


Leiil 


.V  <•"<■  ease  of  ,„„.,,  ,„^.,,j 


les,.,  Ill 


ore 


I  null 


l"''i''''"tly  of  hon,.- 


''^/;"<'    J^I<^i^«-I..T).  and   whetl 


•»«<'lioiis   leiil^ 


o;fenoiis   lenh..,.. 
pi'i'tieiilarlv  of 


'<■'•  a  spl,.,,,-,.  h.„k 


[einia  has  I 


lecn 


■in  IS,  however,  sharp! 


,"'■•"•'•""■ '•''■■'iW'swoidd  seen,  d 


ii'iiiia  can  o,.,., 


|rali'y,  1111(1  tl 
mliT  two  h 

li 


lere  would 


•'"■''"'■■'"■•'''•'""  fl'<"otli,.rsl,otli  el 


""'"'■"I-      The  Jvninl 


ir 


^eciii  to  he  ;,  tenil 


"="""M'^-(I)splenic-n,veh, 
";""■'■  '•*■!""■''■<'  ""  '■-'t<'.^»ii.al  type  ,i 


l<'"''y  at  present  t 


""i<  ally  and 
"f^''-oMpallh.|,ha.n 


latie 
iiiiatonii- 


'y  .ons  and  (2)  lymphatic  \,ul 


lias 


ipparatiis  of  the   l)„w 


|l>'iii|tliiiti( 


and 


1"'  eharaeterized  |,y  ,.| 


•'I'liiia. 


•leiiieiits  of  tho  sj. 


"P"'-'    '■'!   188.->  recorded 


'"I'ges  in  the  lymph 


atie 


i^''"iMiaiiie|ym,,ho,jj., 


'<"'  were   first    involved—; 


a  •"I'^e  in  which  tl 


teii'viinr(>a| 


lyiiipli-element 
"•'■""'.  ='^  we  shall    point 


ma  ])oriii 


eiosa. 


Tl 


'"  alllvtion  to  which  h 


10 


s  seem    to    h 
out   when 


"'  '"'ses  in  which  th,.  t 
pniiiarily  alfectc-d 


iiisill 


ar  and 


"•<"    '^P'-ik  of  tl„.  etiol, 


are 


)f 


peculiar 


A  ilisti 


iicti 


on 


bot 


iy  of  the  d 


is- 


priiicr  is  1,1, 


K'h   h 


Etiology— XotwitI 


woon  aent(.  and  el,,.,,. 
""""•"  f''an  the  latter, 


'SS     (•( 


'.nival  ari( 


''acterioloi,.|Y.a| 


'■^tamliim-  most  earefn!  c| 


,'';"•■  '^  "'""«t  as  nrofotuul 


m  Iciik 


ti'iiiia  IS  a 


prof 

(specific 


iiivestijration    the 


'^"'""■a  is  j.istitial.le,  l,„t  the 
'"'^"''  ■^f"<'.v  and  thoron.di  his- 


new  as  it  was  half 


^^•'•^■t  of  the  eanstitivo  fi.ct, 


ir  ir; 


iidectioiis  d 


'*'■•'"' "'••.^■a.uo.     The  idea 


'«oaso  (KJehs,  Osterwohl    . 


>ux) 


lias. 


!   'i 


I 


V' 


214 


nj.sj:Asi:s  of  the  hlood. 


however,  jfaiiied  groniul  during'  the  past  decade.  Histologically,  thriv  ;,|.o 
n;aiiy  points  of  rcseniblanco  between  ieukieniia  and  the  inf'eetions  granulni,; , 
and  this,  tal'.en  with  the  fact  that  the  acnte cases  running  a  fatal  course  in  ,i  il^ 
davs  or  weeks  with  high  temperature  correspond  throughout  to  the  (linii.ji 
j)icture  seen  in  the  acute  infectious  processes,  goes  far  to  make  a  micro-oiMaiii- 
mal  origin  ])rohal)le. 

An  interesting  case  has  been  recordcHl  recently  by  Obrastzow,  in  whirh  tli. 
atteiidant  of  a  ])atient  suffering  from  acnte  leuka'Uiia  developed  the  sam<' (|ir;iM 
and  (lied:  this  suggests  not  only  infection,  but  also  the  possibility  of  direci  iiiiii;|. 
gion,  but  inoculations  with  Icukicmic  blood  have  so  far  been  without  ii-uh. 

Since  Hi  nterbcrger  in  Nothnagel's  dinic  pointed  out  that  by  far  the  laigiininr. 
ber  of  the  acute  leukiumias  are  accompanied  by  a  stomatitis  or  by  intestinal  iiltcia- 
tion,  we  are  tempteil  to  regard  these  not  as  complications,  but  rather  as  |>iiiiinr. 
affections  affording  a  gateway  of  entrance  (infection-atrium)  for  the  Ii  likn'm;, 
virus.     A  patient^  with  spleuie-myelogeuous  Icuka'uiia,  who  entered   in\(liir 
in  August,  1892,  gave  a  history  of  a  dysenteric  attack  two  years  previ(iii>|v— 
/.  ('.  in  the  snnnner  of  1890 — but  dated  his  splenic  eidargcment  only  frui.i 
February,   1892 :  while  the  splenic  tumor  nuist    have   existed    loiiucr  tliini 
this,  yet  the  eases  in  which  a  leuka'uiia  has  beei    preceded  by  intestinal  loi.ni- 
occur  far  too  fre(iucntly  to  allow  us  to  regard  the  circumstances  as  racnlyair:- 
deiital.       Troje  has  specidated   further,  and  suggested  that  in  the  ehidiiic  jm. 
kiemia.-.  wliere  enlargement  of  the  cervical   lymph-glands  occurs  lariy,  fii 
virus  may  have  entered  by  way  of  the  swollen   tonsils.      At  a  recent  incdicil 
meeting  in  JJcrliu, '   TroJe    idvanccd  the  theory  that  the  so-called  |)m'||(1ii-|(  i- 
ka'Uiia  represents  a   leukaiuic  condition,  the  forerunner  of  a  true  lenkitiiiii. 
AVhilc  cases  which  have  been  delinitely  diagnosed  as  pseiido-leuka>iiiia  li;i\v, 
under  the  eyes  of  thoroughly  eonipetent  clinicians,  been  ol)scrved  tn  jia>-   ii 
into  true  leukaMnia,   yet  the  statistics  are  too  limited  to  permit    us  to  liniij 
that  such  a  relation  is  constant.       The  j)eculiar  disease  occ^urriug  in  cliildMi 
under  two  years  of  age  first  described  by  von  Jaksch  (who  named  it  "aiiaiiii:! 
infantilis  pseudo-leukicniica  "),  and  sid)se(picntly  by  Luzct,  in  whieh  cliiii.iii. 
one   finds   the  spleen    somewhat   enlarged,  the   blood   oligocythien:ii'  wiili  an 
increased  number  of  white  blood-corpuscles,  would  seem  to  staiul  in  an  iiiii:- 
mediate  position   i)etwecn   the    pseudo-lenkiemia   of  ITodgkin  and    Troib^iiin 
and  till'  truespleuic-myelogenous  leukiemia  :  where  tiie  atfection  is  imt  iiiniin- 
ated  early  by  an  associated  gastro-enteritis,  the  blood  may  assume  ilic  rli;ii>- 
teristics  of  a   true  lenkjcmia,  the  so-called  "hypertrophic"  leucoiytcs  luiii. 
present. 

So  tar,  no  micro-organisui  has  l)een  definitely  ])roven  to  be  the  ean^r  nt'iln 
disease:  the  monads  of  Klebs.  the  cocci-like  bodies  described  by  IJyidni  llniiii- 
well,  the  iiacilli  of  Majocehi  and  l>icehini  have  ])rol)abty  nothinu' to  dd  wiiii 
the  atfeclion.  Kelsch  and  Vaillard  report  a  case  in  which  they  funml  li;uilli, 
and  recently  Pawlowsky  of  Kiew"  describes  a  bacillus  which  In'  rlaiin-  i- 
peeidiar  to  leukiemia  au<l  which  he  found  in  six  successive  cases.    'riiinivai:I-iii 

'  Iktit.  //(.'/.    H'nr/,.,  hS'jL",  Nil.   IC.  '  Ihnt.  iiinl.    Wuch.,  iMi-J,  Xii.  J\ 


till'  rail-^C  nl'tli'- 


'   '•"""«1«'<1  <'M(ls,  :,n,|  ,,Mi   l„.  ,,,| 


'-'»■*  "<'•  Ik'cii  uI)Ic,  I 


tiviltrd. 


lovcvcr,  to  1 


215 

.'lltlldlloll     iidt 

••■prniliicc  till'  (lis- 


jri-ow-  ill  slioi-t  rods  witl 

nil  tl rdiiiarv  iiicdra.      Ifc  | 

ciisi'  I'v  injection  inf,,  aiiiniali- 

Wlmttli..  fn„.  natnn.  ori|„.,li,,>.„,.  J,  ,•.,„„    ,•         ,.  , 
o|Mi  ;  >ram.|y  aiiv  oiu-  iiovv-a-.lavs  lool--' ,  o      'T  '""''  ^^'"  ''"'•■'^ 

- '■  ti-  I.atl.olo,i..al  ..Iian,.s  ,01  -  ^        '2   !!;"'"'  ^'""'^-  "^  ='"  "■^l"- 

i  I-"  -tos,  11  o,.,.nnv<l  in  .Moiit.val,  2   in    P  id,  ,  ,    '"    "  r''^*'^  "^  "'"■'•'' 
ii-c.|Mcnt  in  ti.o  SontI,  '       '       ^^  ''"''■^  ""^  ■^'''■>"  (<•  !-<■  more 

r:H.<  uoro  males,  and  the  dis.^ase  is  nn.lo.ihtedlv  "         •    ""  "'   "'•^■ 

or  m  ..ases  eolleeted  I.v  BiHi-iriJ         '^      ,    ,!  "'"•'r"'"  "I  ^--'"^  =  ^liiis 

AltlioMol,   the  maioritv  of  the  .v.f  '"'*''  '""'  '^^  '''"'"Ic's. 

'■■:-.  "0  deHnite  inHneil  !  .   t  S Ir;:  '^^T   ^'l"   '--  =-'  -'.Ho 
Mental  worry  and  depression  Inve  '  T    '""'  ■^"'"^"••^- -'"'itions. 

Li-y  of  iniu.,-a  Let  to  ^J^M.  B^C:;;:^  ^^^'^Voslu,  ean.es.     A 
:  -^  -f-'i.-t :  3  of  my  patients  laid  I         I  '""^.I'^'-r^''  ':"-^-"- 


•^  ""^  -f-'l.'-t :  3  of  my  patients  la  1  ^  ^^  Z  -''7^'  ""^■"^'""- 
'li--  to  Lavin,  straine,rti:„n.elve;  ,  V  t  ""l^j  ^  'I  'T'  ^  r"'""^  ^''^•''• 
-■^<  '■•"■"  a  l.orse.     It  seems  Mnit<.in,n;o..    ."Z'""'  '  ^"  !''"  '■"•-t^  <"'  a 


i^i"'<  '-•"■"  a  l.o.;>.     It  ;;„        d     i"  "^^V;--';'^'"^'  --•  >  to  tl.  em.ets  of  a 

-  ",.  a  process  of  ,1;^;^;^  •""^•' -l>-'>al,Ie  that  t,...matisni  hy  it.df  eonid 

n.l  hi^tory,  and  over  one-third  of  niv   "i  '     "''^''''^  '■''  ''''*'  ='  ■""'a- 

..lalarial  invM>ion.  ■      ''■^'■'    '""'    i"-«'^-'o"sly  Miffered   from 

f"   ''""='''■  patients   the   afi^etion   most  often   develo.n  .t   the     V        .    • 
tli'md.  pnonaney  would  seem  somexvlnt  to  nr,.,i;  '  '•Imiaeterie, 

•'^"- '^  -  ^f-t-a.  ,.ass<.d  thro:;^rt;r :::::,;::  ■;• ' '— ^• 

'"■•■asioi,  a  iion-lenkaM.iie  .-hild      Tint   i.r...,.,l,V  '^^"■"""■^'    ^'«»'"'g  "i.   each 
^'-•^-'  I'v  this  same  case   si„  '    H.  '  V"  '    ""'■""'■'  I''"-^'"^  '^•^'"^  Part  is 

'-•  '•''"<'■•""  <li«'.l  of  tiiet^    .;      r  '  r^^^r^'T:^"  '-''---a,  and  two 
''-''• '''•'•'-'^'•-''-Ithymir^st^^^^^^^ 

I>n,::s  not  mfivpiently  have  Ieiika>mia   aii.I  it  I...    1  1        -,     , 

--.  ''ars,  swine,  and  mice  (Bollinger,  liCt,,)  ""  *'""'''"''  '"   ''-«^«> 

Symptomatology.—Thc    onset    ^-  ,   fl  I     • 

-  '•-  i-iious  that  the  splenic  Z!.\:tm  JV'"'''''''''''  J^"'-'-') 


;  liii'ii  iii. 1,11V 

I'liiii)  ill 


patient  sntfl 


iic  s 


itliat  liHiii- 
and  III 


idc' "  that  he  first 


i"s  iiiiich   itiooiiv 


eiiieiice. 


foiisnlts  the  pi 


='  'a''S'«'  l>art  of  the  ai.d, 
A^  a  ride,  it   is  for  this 


l(ir 


ll'l'  sv 


''lii|ito|ii>  o|(|,| 


'<'•'  ,a"fti,i.r  short  of  breath  and  has"„al 
"iptouis  common  in  aiiaMiiia.      I< 


'vsician,  or  perhaps  he  not 


1  occur  early  ;  tl 


liey  may  even   precede  tl 


palpitation  of  tl 
pistaxis  and  .^ast 


ices 


If  hear 


•t.  pal- 
i'<»-iiitestinal 


le  ( 


"'•^•'t  of  the  disease. 


!:f      "   I 


in)i 


!'S 


t 

I 


216 


/)/sj:as/:.s  of  '/'///;  liutoi). 


ic  (icciirrciicc  nf  a  prt'vidiis  dysciittTv  we  liiivc  already  rciiiai 


On  t 

'aro  iiistaiK'cs  in  wliii'li  a  sudden  or 


kcd. 


I'atal  liRMiiorrliatic  lias  been  the  lirst 


toMl. 

be 


1m   line  (il    the  eases  ot    my  series  a  buy  who  diei 


d  oi'  liaMiiateiiie 


lil'I'C 


ll:ii| 


en   twii   davs   before   apparently   ([iiite  wei 


and 


iiad  j)layed   in  a  i;ai: 


aerosse, 


Tl 


le  syinptoiiis   re 


i'erabie  to  the  stoniacii,  such   as  a   teeliny;   oi"  ojjpi 


after  eatin«r,  nausea,  and  voinitin<>;,  are  rar 


■Iv  al 


)sent. 


he  voinitint!;,  in  I'uri, 


often  appears  e; 


rlv,  and    is  at  times  a  troublesome  featiu'e.     The  1 


)0\\i 


;iri 


isuallv  loose,  diarrliu-a   freiiiiently  oeeiirnn-^  early  m 


tl 


le  disease  : 


this 


to  bo  more 


Ire 


('(iiien 


t   in  those  eases  in   which  the  lymph-foUieles  of  || 


II   lilt' 


tines  are  iiivo 


4 

Ived.     The  stools  ar(>  tiiin   and  watery  ;  in  some  eases  then 


a  true  dysenteric  ])roee; 
are  ^ivn   in  the  iieces. 


ill  the  colon,  w 


■ith  te 


nesmib 


and   niuciis  and 


The  1 


iver 


be 


comes  enlary;e( 


Hut 


common,  but  mav  result  from  o 


d  at  some  stages  of  the  disease  ;  jaiiiidi(v  i> 
bstruction  due  to  catarrhal  iiiHammation  nt'il,,, 


duet  or  to  pressure 


.f  tl 


10  ir 


lands  in  the  hiliis  of  the  liver.      Ascites  m 


prominent  symptom,  a 


nd  is  probably  due  either  to  the  splenic  tumor  or 


tn  tllr 


)ressure  o 


t'  onlarircd   inlands  on  the  portal   vein.      Willcooks   has  dociilh^ 


leiikiomi 


e  peritonitis  due  to  new  "; 


rowths  in  the  niembrane. 


The  lilooil. — No  mattt'r  what  the  form  of  the  disease,  it  is  the  blood 


rNlllii- 


in 


[ition  alone  that  oilers  distinctive  feature.- 


W 


e  liave  aireadv  meiiiumcii 


ditVerent   forms  of  lencocytes,   and   the  relative   proportion   of  those  of 
form  to  the  whole  number  in   health.      In  tiie  lieno-niyelonjonic  forMi>  ,A 


(Mcl 


k 


iLMiiia  the  mo: 


;t  striking;;  blood-chaii_<>;o  is  the  enormous  increase  in  I 


le  lllllllllif 


of  the  white  cells.      Instead   of  the  normal   proportion  of  1  white  i( 
KKH)  red  cells,  tiie  proportion   In  Icukicinia  may  be   1  to  10  or  1  t 


,1(111 


o   ••),  111'   till' 


two   kinds   mav  occur   in  cipial    iiuini)ers  ;  indeed,  tliere  are  cases  recni( 
which  there  w<'re  actiiallv  more  colorless  than  colored  elements.     A 


blood  from   the  iiiiii'er-tii)  in  a  we 


11- 


mar 


ked 


ease  wii 


l)e  mor<'  or 


llrnp  n| 
tlU'iiiil, 


reddish-brown  in  color,  or  in  extreme  cases  possibly  clioeolatc-coi 
often  a  sinirle  tilance  thronjih  the  microscope  at  the  fresh  blood-sl 


ored 


I'i'V 


Ide  will  -cltlr 


tl 


le  tiiagiiosb 


M 


ich  discussion  liad  taken  place  i)eiore  we  w(>re  well  :iri|u;iim 


with  the  aifectioii  as 
wliite  bloo'i cell 


to  how  great  an  increase  then;  must  be  in  the  iinmluini' 
11(1  what  relation  of  wiiites  to  retls  is  necessarv  to  nuMii'iiil 


leiiKa'mia. 


After  this,  when    l^^lirlich    had  pointed  out   that 


;i>  ;l    Vlllr  tl;' 


lis 


c'osmoplulous  cells  wer(>   inereasec 
reyrarding  an  increase  in  those  i'< 


isease,  clinicians    weiu  iwii'av  ml 


in   th 
lis  as  |)athogenic  of  leuka'iiiia.     \\'\ 


true  that  they  are  generally  both  relatively  and  absolutely  iiu 
no  means  alwavs  the  case,  and  besides,  we 


nil'  It  I- 
reased.  tills  i-  liv| 
n"ist  not  ibrget  that  tlii'ir  iiiiiiiiit 


mav 


health.     The  lymphocytos  (Plate  1,  Fig.  1,  h,  b,  h)  are  ivh.tiv 

in  number  ;  instead  of  making  u[)  20  or  .30  per  cent,  of  the 

of  white  cells,  these  small    mononuclear  ibrms  may  he  reduced  tn  less  than  1 1 


(■|\    illlllllll-llril 
wltn'r    imiiil'i-rj 


)er  ce 


nt. 


The  leiicoevtes  \\ith  polymorphous  nuclei  and  neutropliilir  t;' 


(Plato  1,  Fig.  1,  (',  <)  may  ho  present   in   normal   [>roportioiis 


u-ii;illv 


raiiiiiis 

IlllU- 


|L^-j  I 


tt 


-Hi 


:te 


titn 


-t-hr 


•  be  as  i>-reat  or  even  greater  in  c(>rtain  other  aifections,  and  even  ;it  tiiiii'- iiiH     - 


liirUcd.      .  iici,, 

tlic  lirst  -.  11  i. 

■matoiiK'-i    liiid 

ill  ii  jH'ai;  ■  ,.( 

;  of  ()|ipiv-. i,,ii 
initiiii";,  in  I'ari, 

TllO    l)()\\i  i>  ;|h 

so:  lliis  i-  siiii 
cs  of  till  in|..„ 
('  cases  ilirrc  i. 
KMis  ami  li|(i,i(i 

jaiiiidicc  i>  II, i| 
niinatiiHi  ui'tlir 
scites  may  Ih-i 
'iiiiuir  HI'  til  111,. 
lias  (locribcij  n 

lie  hluiiil  I'Xaiii- 

•  iiiciitioiu'd  till' 
['  those  lit'  I'licli 
('  t'onii-  III'  Icii- 
'  ill  till'  niiiiiliiT 
vliite  III  :>i){\  ,,r 

if    1    to    '),   111'   ih, 

scs  reeorili'il  in 
ts.     A   (lrii|i,i|' 

or  less  tiu'liiil,  j 
■Colored.     \'irv 
-slide  will  -iuli' 

well  aei|ll:lillliii| 
1  the  iiiiiiilicrni' 
irv  to  eon-tii'ili'l 
at  a>  a  rule  tl:i'| 

Weill  a<tr;iy 
la.      \\'llilr  ii  i-l 
eased,  this  i- liv 
at  thi'ir  iiMMilicr| 
(■veil  at  tiini'-inl 
.veK  iliiuiiii-linl 

•  will  lie    llilllll'H'j 

'd  to  less  than  ll 

•opililie  UTllllllli'M 

;  U'iiiillv,  li"U-! 


)l 


21« 


eve 


DISKASKS    OF    Till:    lil.OOl). 


tlicv  arc  rclalivclv  (Iimmishcd 


iiiKl  mav. 


-pccially  III  the  later  stay 


vcrv  Ccw  ill   iiiiiiilu'r. 


Ill  tl 


ic  dry  prcparatiniis  tlic 


iiiiiiicniiis  hriy-litlv- 


-I. lined 


Cdsiiiopliihs  (Plate  I.  Fiti'.  1,./')  i"onn  a  striUinj;'  |ii('tiire,  but  in  tliis  vmiiiv 
of  leiikii'iiiiii  tile  iiiDst  important  charat'teristie  ol'  tiie  l)looil  is  tlie  |)ir-iiic,. 
of  e(>rtaiii  cells  wliieli  may  lie  said  not  to  occur  at  ail  in  normal  Lidm], 
Tlioc  cells  closely  resemble  the  larji;e  inononiiclear  leiieoeytes,  but  ditl'ci  IV,,;!, 
tliein  in  -cveral  important  parti(!ulars.  Klirlich  has  studied  them  will 
care,  and  first  described  them  as  hw^rv  m 
til 


ononiu 


lear  I 


onus  eontainiiit. 


UIVJl 


ickly-sct  e-or  neiitrophilic  uramilation.  lielieviiif:;  that  they  ori<>;inat(il  in  ih,. 
boue-marrow,  he  has  named  them  myelocytes.  (Plate  I,  Fig.  2,;/.)  in  mi,, 
of  my  eases,  in  which  the  blood  was  e.vainuied  by  Thayer  according  to  Kliiii(  h'. 
method,  these  myelocytes   at   one   time   nia<le   up  nearly  2")  i)er  cent,  nf  il,,, 


wlioic  num 


ber  of  white  corpuscles.      II,  F.  Miiller  has  described  lar^v  wjiit,, 


y  mii- 
'  lai-,- 


elements  in  the  blood  in  this  disease,  varying  in  size,  but  lieiiig  usual 
third  to  one-half  larger  than  the  ordinary  white  cells;  the  nucleus  i- 
j)luiiip,  and  oval,  and   usually  lies  exeeiitrically,  und   its  intramiclear  ni  iwmk 
is  more  delicate  than  that  of  the  ordinarv  leiico(^vt( 


surrounded 
immcrouf 


i>v   a 


in 


tl 


lese 


the  cell-body 
^lightly  thickened    iayc.'r  of  cell-suiistanee.     Mito: 
d  ]\Iiiller   has    shown    tliat    nreciselv 


i> 


an 


-innlar 


eel 


and 


k; 


iryokinetic  figures  occur  in 


the  1 


)()ne-inarrow. 


Minilar  (vlls 


also  been  described  earlier  by  Coriiil  and  were  iiained  by  him  ci'l/ii/c' 
la 


■iJiil. 


urn. 


.My  own  study  has  convinced  me  of  the  importance  of  this  | 


leenliai'  ci 


form  for  the  diagnosis  of  a   myelogenic  Icnkiemia,  and  I  have  no  donlii  tli;it 
Fhrlich,  Cornil,  and  Miiller  have  been  deseribing  under  dill'erent  naiiKstli 


same  morn 


hoi 


oii'ica 


1  el 


ement. 


Occasionally  there  are  leucocytes  in  the  blood  of  leiikfemic  patient^  wlurh 
contain  basophilic  granules;  they  are  by  no  means  always  to  i)e  foniul.  A-;i 
rule,  there  is  no  marked  oligocythiemia,  the  red  corpuscles  rarely  guiii;;  lnwu 
than  two  millions  per  cubic  millimetre  ;  the  amount  of  Iwemoglobiii  eoircsiiiiini. 


to  the  decrease 
1)1 


e  or  is  reduced  in  a  somewhat  greater  proportion. 

ibh 


\ 


iclcalcd  ivi 


ood-corpuselcs  are  present,  and,  as  a  rule,  in  eoiisideral)le  immliers  ;  lliiv;ii\ 


latr 


chiefly  iiormoi)lastic  in  type  (Plate  I,  Fig.  2,  /*),  but  megaloblasts 
I'^ig.  2,  /)  oct'asionally  occur.  (  ascs  with  the  blood  of  the  type  of  a 
aiiiemia  have  subsc(pieiitly  develoj)ed  a  true  leiikieinia. 

In  the  ])ure  lymphatio   leukicmia   the   blood-condition   is  quiic 
Here  one   never  meets  with   the  enormous  increase   in  the  miiiibcr  of  whiti' 


Irl'MK'liill. 


Icl'clit. 


1   tu  10 


cells  deseriiu'd  as  characteristic  of  the  ordinary  form,  a  proportion  n 
being  rarely  exceeded.  The  increase  takes  place  solely  in  the  siiia 
nuclear  elements  (lyinj)hocytcs),  the  large  mononuclear  and  polyiiiKJcar  fimii- 


iiiiiiiii- 


beiiig  relativelv  grcatlv  diminislied  in  number.     The  eiiori 


nous    (ll>|l|-0]Hi|'lin|l 

is  well  shown  in  a  ease  described  by  Uthemaini,  where  ',)'■>  per  cent,  ol'  all  ih 
white  cells  were  lymphocytes.      Kosinophilous  cells  and  nucleated  red  corpii- 


cles  are  rare  ;  mve 


loevt< 


are 


as  a  rule,  not  present  unless  there  be  an  asMiciatiil 


disease  of  the  boue-marrow. 


|llltr  i|lll<Ti'Mt. 
llllicr  lit'  wllilr 
tinll  (if   1  to  10 

t'  snuill  iiiiiiiii- 
i'liiiclcar  liinii^ 
;  (li-|)ni])iii'liii!i I 
colli .  of  ;i!l  till' 
tvi]  ivd  cnrpii" 
)('  an  a>^ut'iati'(l 


i-I':vk\i:mia. 


-Iii.-it  as  tl 


21 !» 


i»'i'<' aro  Milxcd  forms  oflrHil, 


imiy  <k'viat(.  /h.1,1  til,.  t\v„  typos  ai 


l<";"'ia,|,„H-ovor,sotli(.  I,l,„„l.,,,„,| 


wlii'lic'am,.,„tu,„ydinio.,t(lu.J,,|.„sn.,,,[ 


»'»vc  -ivoii.      J„  a  ^,,.,^,  „(• 


itioii 
iii'iito  loiiliiuiiiia 


ivdl  as  tlu'  splooii  and  I 


x'lio-iiianow  woiv  afUrto,! 


'l''<i"sir,.s,,ital,ulK,,,(|,     ,i.„„, 


|.n.|inrti.m  „f  ly.nphocytos  ami  .nvol 


(Vtcs  wc'iv  prosciif. 


<'t'ytos,  iuaiiv  lai 


'"  tlu'  bl(H)(l,  lusidcs  a  1; 


Is  as 


■ge  moiiuiiiicloar  Icmrh 


111   l( 


■iilvODiuiL-  bl,„„|   Olio  not 


liiiii'i'.vtcs  (It'void  of  tl 


iiif 


rc( 


-vm 


!<-'  usual  £-gniiinI(..' 


ijiii'iitl 


y  linds  a  niiinbcr  of  pol 


polyniiclcai 


'"'  ^^•ant  of  a.ii.oboid   niuvci.u 


''  l'''<''">"in.on  as  yot  not   mid 


Miku.mia  uas  first  p„i„t,.d  „„t  bv  C'alidV  •  tl 
wv.smY.ms  Icnkii'mic  blood  will 


"t  i.._  the  nhite  .dis  oV  tl„.  blou.l 


MS  \f 


I'liiiiation  is  easy  to  find 


'  "onnal  spci.iiiK.ns  on  tl 


particularly  noticeable  wl 


cr- 
in 


ion 


polvmicl 


,  smco  wc  know  that  of  tlic  1 


'•'  warm  stajrc.    The 


iiiii 


iiits  to  be  mentioned 


!t'ar  fbrms  which  I 


are- 


lave  active  amoeboid 


fiicocytes  in  health  it 


IS 


nimsnally  dense  fibr 


(Ijtl 

■ill   network   b"t 


IH'anmo,.  of  Charcot's  octahedral  cn-stal 


i«'  abiindance  of  blood-phitos 
^"wii   the  oorpiisck 


inovenicnts.     ()t| 


ler 


"1  many  cases; 
"id  (;})  the 


;i'lit  Cor  a  short  time 
r/(c  ( 'iiVHlittory  S,i.sfaa.~li 


T'^tals  in  blood-slides  which  have  I 


K'OIl 


ilif  Ilea  I 


t.altl 


loii"!!  the 


i^*  Hire  that  the 


e.ila.Ke.1  spleen.     The  pnlse,  thoiitrl/l 
|;iiiil  ol   low  tension.      (Kd 


'l>;'X-lH'at  may  be  displaced  coiisid 


■«'  are  symptc.nis  referable  U 


'I'abl 


J,^"  large  in  vohiiiui,  i 


.\' upward  bvlh 


nil'  toward  the 


i-e  from  the  nasal 


011(1  (,f  the  (I 


L'uia  of  the  aiikl 


isoase. 


Hi 


<'.'^,  or  even 


In  two  cases  which  i  I 


I  imic(.iis  membrane  boin.r  tl 


eniorrhages  are  conn 


•s  usually  fmpient,  soft, 
general  anasarca,  imiv 


lave  seen  fatal  I 


K!  most  fre(|uont. 


i"»"  iu  all  stages, 


»>in.ysuspie,onof  ancM-sting  leuk 


'••'hral  apoplexv  was  tl 


kioiiiia. 


liieiiiatomosis  oceiirred  before  tl 


H 


Oil 


-I'liiic  retinitis"  [>■ 
n;i!  Olid, \ .vs.— 


aiioti 


i(!  cause  of  death  i 


lor 


manifestation  of  the  I 


ii'uiojjtysis  and  h 
"  one  case  of  niv  ser 


lore 
ii'uiatiiria  are 


10." 


Tl 


le 


The  shortness  of  breath   is  d 


''■';''f'<"'  ^'\ving  to  the  oligocvtluemia.     Tl 
'-"•any  symptoms  until  toward  the  end 
"""""""  ""i.v  «irry  off  the  pat 


lieiiiorrhagic  tondeiK 
uc,  as  a  rule,  t(,  defi 


'\ , 


•ililc  I 


It-'  iungs  are  scared v 


ICIOllt 


K.'llt. 


of  the  disease 


over  respoii- 


',  when  U'dema  or 


li  ^vc  t 


x«v|.t  t\Hi  cerebral  symptoms,  si.cl 


winch  are  assodated  witl 


1  as  headache,  di^/i 


'  ariiomia,  the  central 


iH'ss,  and  faint- 


■""""" '•*':""'''';'"^'<-^'"'-       Wohaveahiad 


uorvoiis  system  d 


"lililCIl    ('(11 


iia   fbllowinu-  | 


l'"'"'i'"'  i'''iinitis,  which  is  I 


K  liit'inorrhage   from  one  of  tl 


y  spoken  of  the  oceu 


oes 


|f:l!(ilc,-. 
ffilinlis 


'"It  tliore  arc  al,- 


»y  no  means  rare 


le  cerebral 


f'roiice  of 


vessels. 


"I   ro,iiid-ee 


in  tl 


^'»  ■sometimes  true  leiil 


',  consists  dii(>tlv  of  I 


licariiiM-  is  iV( 


K'  retina. 


Kii'Miio  now  growths  with 


The 
laMiiorrhagio 


lfa>c, 


As 

Ml  as  10: 

iiiii'i'vals  ,1 


a  riil<. 


■  }0 


■quontly  affected,  and  di,,f 
',  the  ^'iiipcraturo  is  i 


'•'""""•^  optic  noiiritis  is  not 


'less  may  ( 


aggro- 
c'omiiion. 


or 


lO.T  F.,  but  periods  of 


"ore  or  hss  elevated 


■OHIO  on  early  in  the  di 


"oniial   temporafun 


J>yroxia  may  alfernat< 


ranging  at  tii 


110; 


as 


wit! 


'  J'l'olongod 


I  nil  .ill 


'iiii'H'  may  be  all 


iiiriiial   iiicrea 


Juuiiiious,  but  it  is  bv 


Wim's  may  sfaiid  in  d 


''<'  '"  (he  aiiioiiut  of 


"o  ineaiis  always 


ui'ic  acid   o.\( 


'J^l 


lore  IS 


I '-Oct  relation  to  the  spl 


•ivtcd,  which  Salkowsk 


It'UiV  oulargenient.     Tl 


J 
Ik'  cause 


1*1 


220 


DISKASIJS    or    THE    lilJiOl). 


I 


III 


of  llic  persistent  priapism  wliicli  ol'tcii  occurs  i-;  iinkiiowii.  In  a  case  roc  i,|,.,| 
l>v  Kdcs  it  was  the  first  symptom;  it  may  persist  for  days  or  even  .,|:. 
(IVal)o(lyK 

yV/c  Sp/rtii. — Wlien  a  patient  siilfcrint!;  from  lieno-mednllary  leiil  rini:, 
first  consults  tiie  piiysician,  the  s|)lceii  is  nearly  always  mncli  eidaro'cd.  mid. 
tliouiili  nsnally  somewhat  tender,  may  jiive  rise  to  very  little  ineonveim  n,.,.. 

Its   i)urdcr  will    he    felt   in    the  left   side  of  the  ahdomen  as  a  iiard,  .-c il, 

rounded  lump  which  rolls  over  the  fin^^er-tips  with  each  fnll  inspiration.  Tl,, 
oroan  when  much  enlar<>('d  may  extend  as  far  as  the  navel,  and  I  haw  rvin 
seen  it  fill  the  whole  left  side  of  the  abdomen  and  extend  into  the  riuln  ili;i,. 

Kio.  12. 


("use  (if  I,it'iiii-nu'(l\illiir>:  lA'tikniniii-clKiwiiij;  t'liliirKOiiRMit  (if  si.lccM. 


fossa.  (See  Fig.  12.)  One  can  sometimes  feel  a  friction  freinitii-  dvcr  tin- 
tumor,  and  on  auscultation,  besides  the  rub,  a  "splenic  sontlle,"  ^y-tnlir  in 
rhvthm,  may  sometimes  be  heard.  (Jerhardt  has  described  a  puls.itiiij,'  s|(k(ii 
in  one  of  his  cases  of  leuku'inia. 

That  the  tumor  is  the  spleen  is,  as  a  rule,  easily  decided   from  tlic  i)n<iliiiii,| 
form,  and  feel  of  the  enlaru;ement  ;  moreover,  not  infrecpiently  (hic  i- abli  t^ 
clearly  make  out  a  notch,  or  even  several   notches,  in  the  anterior  iHndcr,    It 
varies  much  in  size  from  time  to  time  ;  after  meals  it  is  increased,  after  liu'iiiMi-j 


I'i:i'K.EMJA. 


221 


rl.ar  o    s  U.V  <luuTl...>a  .l,n„nislu.,l.     As  nn^I.t  l.o  .xpctcd,  prossnro-.ynn,. 
.„.  .    w.t,„.os  ....„,,  sue    ns.lisfvssaft..,.  ..tin,  ..,•  nl>s!,.,„,i.      ..ftl. ".' 
iron   tl...  latter  „t  wl.,c-l.  ,loatl>  has  l,a-..  k„..w„  ,„  ,,.,.1,  ' 

wrtlu'ly.Mph-olaii.lst..  beinu.'li   ,.„lanr,M|-  att.Tt ,.l    ,     i     '  ,       '"■" ''"^ 

.1^.   tlu,  h  „p„u.  ^lan.Is  may  innvas..  i„  si/.,  |,„t  .v.m  tluM,  it  is  th.  s,n  J 
I  ...1  u,„.  wl.u.h  are  ,.nu..-ally  ali;..,,.l.     ()..„  ,„„,,,  ,,.,,  ,„„,.  ,,„.,  ,„.,.,",. 
.I..M,  as  are  tmnd  ,„  the  pseudo-loukic.nia  of  ITud.rki.,       I,,  mm,. 

::|Un.ia  tho  ,y.,.ph.,,a...,s  a. .......aHy  ...a.-^i;';;;;,  t!: ';  ;„;:';:;;: 

.^  ^I..l.tly  so,  but  the  d.soase  is  a  ve..  .-a.  one  i,..„....l,  and', Is'tlX 

TiM.ro  may  bo  sca,.-oly  any  tendorness  over  the  bo,,,.  d„,.i,„  li,;,,  ,.hiei.  at 
..o,.,    show   to   „,ost   adva,.eed   ..,a..,.ow-ei,a„,es ;  th..   patie,.,s     ometim^ 
;.n,.hu,,  who,,  the  sten,,,,,,  ^  ,„„,,,.„,  ,.  „,,  ,.„.„,^,.  „,  .^^^  ^     - 

,.on.      Invgnhmty  a.ul  defbn-.ity  of  the  ribs,  the  ste,.,,..,;..  imd  ...h.,     H  t 

'"'^  "••«'^'"""lly  '-..suit  fro,n  the  leul<.e.„io  bone-.-han-os 

Morbid  Anatomy.-The  body  is  pah-  a.,d  „,ay  be  uuul  nuacM  ;  edema 
h„a  n,ps,ea  of  „s,o„s  a.-o  con,„.o„.  Wl,e„  the  hea.t  or  aorta  is  ope  ,^1  he 
.1  .s  usually  fo.„,d  to  bo  eh,tted,  the  elots  havi,,,  a  pee.diar  ..-ee,, Li,-  'll  " 
hU,  ren  ,...1,.,.  o„e  of  the  fat  of  a  t„.-tIo.  Whe„  tl,e  ine.-L  i,.  th,'  vl  i 
.  ,n..„ts  as  bee,.  ext,.e,,.e,  the  color  of  the  ..lotted  „,asses  ,„av  be  veHowisl 
h  nto,  a„d  .t  has  n,o..e  than  ouco  happened  (as  i„  a  case  of  Virchow's)  that  the 
|olH'rv(>r  on  openiiijr  the  r  irht  auricle  li'i^  Iw.i;-.,.    I  <•  ,    ^ '""' ^"^ 

IWo>olnn,.„   abM.e>..      J  ..  la,-j.e  a.nonnt  of  bloo.l  in  the  hea.t  and  vessels 
;..,.  eworthy  fcatn,-o;  n.  one  of  ,ny  .uses  the  heart-.-han.be.-s  alone    o 
.a.no.l  bloo.l-clots  we,,.h,n,.  G20  ,,.-an„nes.     All  of  the  vessels  u,,,.  en...  "l 
".  t  .  sune  way,  the  po.-tal  vein  Just  above  the  union  of  its  b,-anel,es  n^a:.  • 
|iii;rn  em.  ,n  circumference.  '"<-a,sni 

The  blou,l  has  been  examined  chemically  by  various  observe.-s  with  result. 

wlH.    do  not  altogether  orrespond.     Sci,e,.cr  as  ca..lv  as  1852  found  l.C 

I -ulnn,  laet,e  ae..l,  h.rm.c  aci,l,  aeeti<.  aei,l,  Icucin,  an.l  Urosin  p,.esent,    ,      I 

.n.n„t.o,,  ..f  the  alkalescence  of  the  bloo,l  (it  is  even  acid  at  ti.nes)  ha    b«^ 

l"I  KK.d  .,  be  ,lue  to  organ  c  acids.      The  presence  of  a  notable  ,  ant  tv  of 

Tl.  octahedral  crystals  which  a.-e  found  i,   blood  which  has  been  allowed 
-«ta„,l  lor  so„,e  tune  we.-e  Hrst  describe,!   by  Cha.vot  a„,l   Robin      Tllir 
l..:.ny  ,.as  yet  unpc-fbctly  un.le.-stoo.l  :  s.une  h,..  thought  thenr^e  t,.'^ 
l-«  Gaingoe  claims  that  thev  re,n-cse„t  •,  „h„s„l,.,f,.  Ai  :  ' 

-k;™i  .,  ...,n,.i„„  ,„■,.,:, :,•;„';::,::;:;;;;;;,;"„;:;;;; "'"* '  '""" 

"..  ™an,„„„s  ,1,..  I„,,rl   i,  will  W  fi„„„,  |„„|,„|  „ „  ,,.;        , 


1    '(( 


il 

1 

li  t 

/ 


222 


DISEASES    or    THE    liLOOD. 


<|ii('iitly  present  eeeliynioses,  and  lenkieinie  new  }j;r()\\tlis  may  exist  tli  'v  a. 
well  iis  on  the  peritdneuni.  'I'iie  cavities  of  the  heart  are,  as  a  nile,  dilaicl 
and  the  nivocardinni  soft  ;  if  the  papillary  nniseie.s  bo  teased  out,  a  nwii-jati' 
grade  of  iiittv  elianji'e  is  evi<lent.  Ueyond  an  neeasional  fatty  dej^eiieraii m  ,,f 
the  infinia  there  is  no  reeo<;nizai)le  histologieal  alteration  of  the  walU  ..I' il,,, 


vesse 


in 


As  we  have  said,  the  spleen  is  nearly  always  enlarged.  E.\ternall\  tliiTr 
..jav  be  the  signs  of  an  old  perisplenitis,  with  adhesions  to  the  alKloiiiiii.,] 
wail,  diaphragm,  or  stomach,  the  capsnle  in  these  eases  being  often  t:ivatiy 
thicUened.  The  arteries  and  veins  at  the  hilns  are  enlarged.  The  oruan  may 
vary  in  wei<dit  from  two  to  eighteen  and  a  half  pounds,  the  latter  weigln  i)(.|ii>r 
the  heaviest  on  record.  On  section  the  spleen  is  tn'in  and  tough  and  ilicMir- 
fiice  a  reddish  or  purplish  brown.  There  may  be  throughout  the  organ  \\\v\mt. 
rhagic  intiu'ctious  or  areas  of  a  rusty,  reddish-brown  color,  the  siti  u|'  ,,|,| 
extravasations.  The  Malpighian  bodies  are  not  prominent;  indeed,  i Ik  \  an. 
as  a  rule,  not  reeogni/able.  On  the  other  hand,  grayish-white,  well-dctincil 
lymphoid  tumors  may  occur  throughout  the  organ,  contrasting  strongly  with 
the  reddish-brown  ground-substance.  U  the  spleen  be  seen  in  an  einly  >taL'c 
and  before  the  disease  has  jirogressed  far,  it  will  be  found  softer,  and  ilicic  will 
bo  swelling  of  the  pulp  and  proliferation  of  the  cellular  elements;  ru|iluiviit 
the  spleen,  it  is  sai<l,  has  happened  at  this  jteriod  from  the  excessive  liypi  ricmiii, 
^Microscopical  examination  shows  this  proliferation  to  be  general  ;  Uarydinitniic 
figures  and  large  myelopUupies  are  seen  here  as  well  as  in  the  lylllpll-J:l;ln(l^ 
and  bone-marrow. 

The  Ivmph-glands  may  be  enlarged  in  the  chronic  form  of  lenl<,iiiiiii,  Uit 
the  hyperplasia  is  not  extensive.  Ju  the  acute  lymphatic  leul<ieiiii;i  all  ilip 
lymi)h-<dands  of  the  body  may  be  involved,  the  eorvieal,  axillary,  Micsciitciic, 
and  inguinal  groups  most  frequently,  less  comnumly  the  bronchial  mikI  imdi- 
astinal.  The  glands  arc  soft  and  easily  movable,  scarcely  ever  being  ninttnl 
down  bv  a  periadenitis.  As  in  other  lymph-gland  atfections,  the  si/c  viinV< 
from  time  to  time,  often  diminishing  notably  before  death.  On  xctioii  the 
grayish  color  of  the  healthy  gland  is  not  seen;  instead,  the  siu'fair  ii«iiallv 
has  a  grayish-red  color,  and  there  are  (!vidences  of  hjemorilia^c-  inti  tlif 
substance. 

Till'  pathological  changes  in  the  bone-raarrow  have  been  cJuMly  -tmlictl 
since  the  investigations  of  Neunuinu.  That  observer  claimed  that  the  luodiilla 
of  bones  was  atl'ceted  in  every  case  of  leuUitMuia  ;  there  are  instances,  however. 
where  no  si.^li  changes  are  recognizable.  In  the  majority  of  exaiii|ilcs  of  the 
licno-medullarv  form  described  by  the  (Jermansone  finds  that  tiie  iiovnial  tlitiv 
nun-row  undergoes  marked  alterations.  Examination  of,  say,  one  .if  the  hikI- 
dlc!  lumbar  vertebra?  or  the  extremities  of  the  long  bones  reveals  a  dark  ivii- 
dish-brown  substance  (piitc  different  from  that  s<'en  in  health.  ( )r!;wn!dlv 
there  are  ha-morrhagic  infarctions,  as  in  I'ontick's  ease,  and  as  a  ir-iilt  ot  the 
proliferation  there  may  be  expansions  here  and  there  of  the  bony  case,  fiiiiii- 
ing  localized  swellings.       Smear   cover-glass   preparations,  dri(>( 


the  air, 


LEVK.KMrA. 


223 


l.oa       an.l  f.x..<l  w.th   FI.,nn.i„,V  ..lutinn  or  with   picrio  aci.l,  and  snl^o- 
r".        ta.ned  wh  sa  n.nn.  or  .lilw...  InennUoxyli.,  sl.o.  nn.s    I..aut        v 

.    r    of  (he.  ,no.lM.n.-s,...l  n.an.ou-....||s  wi.h  (h.  la,^.  „ .....car  ..lis  h. 

.1,   Mood      Many  MMtusos  W...V  s....„,  and  n,v..lo,,la,pa.s  .-ontainin.   1,...  Jevt  " 

.  .  .'t  lHK.oc.yto.s^,.annot    h-  snpportod/  for  ...  a.v  ,,n>l.al>I v  h-,; .l.alin.        h 
.ll-."-lns.ons      N„..loa,o.l   red  I,lood-<.o,,.„s..l..s  al..!  .osinophilons  .•  M.     ro 
-  an.       J  he  fnnction  of  th..  hn„.  ,iant-....|ls  of  tho  n.a'rou-,  uh      ,.;  ^ 
Ikilth  or  disi-aso,  w  still   unknown.  >'"in(i  in 

WlK.n.s-c.r  thm.  an>  lyn.phatic  dnnonts  in  th.  l.ody  th.Mv  n.av  1.  lonk^ennc 
e  n,,,.s;  tiM,s  th.    i,ynu.  ,hu.,l,  tho  solitary  and   a^ndnat-d   fi.llidos  i 
"'t.stMK    tho  t<.nsds,tlu.  lyn.,.h-folIi,.I,.s  of  th,.  tnn.n..,  pl.arvnv   and  m  ,ntl     ' 

^,  ^^;;^: '" "'"  i:' ;-•  '-n.  ti.  ntti.  ..oii..;.tio;. '  of  iVn;;i  1  :t; 

I  .  .1.0  ddforont  o.^ans,  „,  the  lungs,  live,  kidnc,-s,  etc.,  n.ay  undi-^o  pLlilb :: 

TlH.  liver  is  frc.,,nontIy  enlarged.  Weh-h  has  deseri[,e,l  a  ease  in  whieh 
,.  wo„l,ed  over  h,rt..en  pounds.  lIistologi,.ally,  the  enlar,,.n.ent  is  see,  ^^ 
N- t.  a  dd h.s.  l.„ka.nnc  ndihration;  the  eapillary  eetasis  Is  extren.e,  and  he 
j.J,n.ns  oJ^Wcells  are  wi<.ely  separate<l  l,y  the  erowds  of  white  eU;.:!;!: 

TIk.  large  leukaMnic  tn.nors,  though  rare-being  seen  o„lv  in  1  .ase  in  n,v 
lJantops,es-deserve  n.ore  than  a  passing  „K.ntion.  Wh„;  thev  are  p  " !  it 
.  the  organs  they  appear  as  grayish-white  uo,lules,  and  show  nderose.  .^^v 
...nerons  eells  undergo,ng  kan-ondtosis.  It  has  been  supposcl  tha  '^ 
h;.™  ,o„sar,se  ro,n  c.lls  whieh  hav<.  enngrate.l  iron,  the  Viood-ves  ds 
"'•;  "^"  '"  '\  ^^^  "-v  growths  ,loes  not  at  all  r..send,le  the  .I  • 

'::;:Xlr- '"'  ''^  ••"'•  -"^  -^'^-^  '^  ^^--^  ^'^  --'^^  this  view  r!L 

Diagnosis.-This  rests  entirely  upon   the  blood-exanunation,  and   in  the 
aionty  o    u.stanees  ,s  easily  n.ade.     In  .h.nbtfhl  eases  the  ditle^nti  1     . 
';■!  tl  ■  wlnte  elements  by  the  n.ethods  of  Ehrlieh  should  not  be  negle    e 
'■-"■■'  l-:'t'<-  a  e,  ..r-analysis  shonKl  always  be  n.ade.     Asi.k  fro,    'tlo 

li:r:::J:::;^::;:rr 

'II  '  oi  a  tas(  tnoenart  of  w  i,eh  ,s  sriven  "it  n   ')17   .,■„]*,         , 

,  ,-.,  „  „  ^,..„  "^  "^"  '"<>()(|.eo,-pi,seles  had  nsen 

'  "A'  H.  I'.  Muller,  Dn,,  Arrlnr.  /  ,W„.  ,/,^.,  ,„,.  ,,,;•   j,  ,-_ 


i|lllKl-('(lM 

III  I  ml 


I  -•  I'l 


22i 


nisKASKs  or  Till-:  iu.ood. 


f 


If 


r   t 


ill  iiiiiiilK'r  to  3,rjOO,0()(),  iiii.l  the  liii'iiiogl()l)iii  luul  iiifmiswl  to  44  jut  wit. 
Could  one  iiiulcr  tli(sc  (•irciiiiistiinccs,  woiiij;  tho  (Uhc  lor  the  first  tiinc.  Iiuw 
inadc  till'  (lia>,m(wis  of  IciikiiMiiia?  It  is  liorc  that  tlic  value  of  Klirlnii^ 
iiicdiods  is  wtll  (k'luoiistratcd.  A  careful  coloi-aiialysis  was  made  In  my 
assistant,  W.  S.  Tliaycr,  at  diiU'icnt  times,  and  the  estimates  given  in  tiir  fnl- 
U>w\u^  talile  were  hased  oii  dillerential  eouitts  of  ut  least  one  thoiisaii.l  ku. 
oocytes  at  eaeh  examination  : 


N"i  niiil 

Nnv.  ',1, 

.Inn  -19, 

F.'l..  7, 

K.I..  H, 

Fell. '.ll, 

K.-r.  ■>, 

Illlnnl. 

IH'.m. 

IH'.ll. 

IWIl. 

IMll. 

IHIll. 

l.v.l 

I.VIliplKH'Vtt'S    .... 

.  20  :m)'/o 

■Z.\'/c 

(».1)(1% 

\.r>^h 

-  1  ,c 

tu»;i 

10    ;; 

rolymii'loiir 

.   .  (i()-7'> 

73.8 

70 

8;{.i> 

84.7 

83.2 

T\l 

.Mdiiiiiiiicliiiriind   \ 
I'liiiisilion  foiins  1 

.    .    ti.O 

■t.f> 

;{.o 

\.r, 

2.1 

2.r. 

•J.o 

Ivisinopliik's 

Myi'locytcs 

.    .    2.4 
.    .    0 

■1.8 
14.7 

215.5 

4:2. 

8.6 

1.6 

8.5 

3.0 
4.0 

1.1 

1.7 

I 


Now,  on  Feb.  2I.st,  while  the  enornions  enlarfjement  of  the  spleen  wdiiM 
have  made  one  think  of  leukioniia,  yet  the  mere  numerical  estinintr  u\-  tlic 
examination  of  the  fresh  blood  wouhl  have  given  no  hint  that  a  l(iiki..|iiic 
i)rocess  had  e.xi.sted.  As  will  be  seen,  however,  by  reference  to  the  above  talili, 
the  dried  and  .stained  specimens  still  showed  4  per  eent.  of  typical  inydocvKs 
and  this  would  have  hinted  at  a  previous  existence  of,  and  the  pcssibility  ol  a 
return  of,  a  lenka'mia. 

An  enormous  leucoeytosis  might  be  mistaken  for  a  leukremie  enmlitidi,,  Imt 
niav  be  easily  excluded  by  the  .stuily  of  stained  specimens;  in  all  unliniuv 
leu'cocytcses  "the  increase  affects  solely  th<'  polynuc-lear  neutrophilia  The 
enlaro-ement  of  the  spleen  in  chronic  malarial  cachexia  or  malign;uit  di-cw 
mav  also  be  ditfercntiated  from  hsukiemia  by  the  blood-examination,  li  iii-i 
tainlv  is  not  ju.-ititiable  to  make  (as  has  been  done  in  at  least  one  cmm'  of  lui-l 
kfemia)  an  exploratory  abdominal  incLsion  to  examine  the  spleen  licll.iv  ilic 
blood  has  been  carefully  studied. 

The  pure  Ivmphatic  form  of  leukremia  has  to  be  distinguished  rimii  trin- 
eral  lymphadenoma  or  Ilodgkiu's  disease;  in  the  latter,  however,  the  uImikU 
are  found  in  much  larger  l)unches ;  and,  besides,  the   blood-eonditiuii  i«  ' 
lymphatic  leukiemia  (piite  characteristic  {ridv  supra). 

Course  and  Prognosis.— In  the  splcnic-myelogcnous  form  the  |>rnirn' 
slowlv  progressive  lor  months  and  years.     Recovery  oeeasionally  ou'in>.  Imt I 
this  is  so  rare  that  when  the  diagnosis  is  once  established  we  can  expect  dci'li 
almost  certainly  within  five  years,  and,  as  a  matter  of  fact,  the  niMJeiityof 
cases  terminate  fatally  in  two  or  three  years.     Certain  symptoms.  :i>  liiiMimr- 
rhage,  high   fever,  severe  diarrhfca,  and  oedema,  will   indicate  a  nipiil  coiir-cj 
The  progress  of  the  atfection  is  very  irregular,  and  there  may  !..•  tniibldit 
intervals'^of  comparative  health,  which  encoin-age  the  patient  I,  ;.  time,  niily 
to  be  followed  ^oonor  or  later  by  a  return  of  the  .symptoms.     I  liavn  kiinwna 
patient  (Case  VIII,  of  my  .series)  with  an  enormous  spleen  to  uvt  iilioiit  tnrj 
months,  attending  to  a  light  business,  when  his  blood-count  showed  a  ratio uff 
1  white  to  G  red  cells. 


ros  ij 


/■A7  7,-. /;.)//.  1. 

J -'livt:  !;;::■;  T:::;-;;;!;';,:;;:  ■'"""- - ^"'  ■■'■ ■ 

""'  ""'-'«'■  K i,„.„  „:,..'  :„:;■"'  '■"-"  '^  ""■  '-"'<  ■"■  «.- 

'-:"l'™l  ^•P"|.l..vv  ,„,,  „„.,„i,:„      ■       "s  "'■■'">■""«'■■"■ 'I-  ■! .-. 

,  »■;  ■■'/ « "'• '"'  ™-^  a,:;;;::    i^;,:'"';.";""'^  ■  '■'  --^  ■',.. 

'    Tl...  »,.,„.r„l  l,,„„l„„i..  ,,„„, „■„,,,',':     '"":'""■ 

...i..r-..-™w,i,.,w,,,/v :/:;::;:::,;;:;;::  "'■''' "■'■"'-■ i.v;-«i., 

■'"^ I  '"•<...-i...  i.i.y,.i..i„„  „'■■'';  i"'.  '"""*■ '" '">■  "■■" 

i-  atl,„li,.M  ,„  ,|„.  |,vgi,.„i,.  s„„-,„„  I  ,        ,■  ""'""■"""  '"  >'">'  l"'"'-"- 

|...li .1-  „ll  ki,„l,,  '  ''" '■  "'"'  '""■'  '""">  «""y  ."..I  m,.,„al 

,*.S;::.::„rr:,:::  :,.;:•  ,::;;::i/'f-  -';« • 

l.;H-ini|)r()viii(r,  ;it    i-jisf  f',,,.  ,,  *:,„„      ,..  kmiii-,  m  my  Jiands,  most 

LU..I,  since  the  o,„.i<.„s  n-nus  ,     ,  '     "''''''''^^••''^:-'  "'' ^' --'^ 

l»  parti...!;...  .  pati.-nt,  u ho  l.a.l   hcon  n.nH  u  '   ,    ■         ;'"'""'  """  ^'^'^'^ 

f.".i".u.a  .,vatM,ont  aM.1   net  to  hi.  ho    ,,  V  ''""""  '"'"'"''''  '"^  '''- 

M,,ho  l>lood-connt  .showi...  ,„a,-l         „  '■'''",""'  '"""'''■^  '''^"'  '"•'••'- 

Jrc  rcnrlR..!.  '  "  ""'  '""''''  <'"«  proeantion,  till  Jarg,.  doses 

I    .r,,,„„,„_,|,.,  ,„,„„,,  „f  „,_.  ,,„7  ,  .7'      "»  l"™'"""t'  i»  tl„.  „,„,,, 
I" '•.■»tv.i;..,r  li,„„f„r  l,,,|<.,„i,,     M  '         '  ■■'l'l''"«"'".v  l.»  !«'.■.. 

I       VoL.ij.-,5  """'  •'^•^•^  "»  good,  and  is  now  srarooly 


k^ 


I  y 


22(J 


itJsnAShs  o/    tut:  nij)(>j). 


'!: 


t 


ever  advised.  Notwilh  'aiuliii^  tlir  tact  that  the  disease  is  almost  alwas  |.i,,. 
|(r>"ssivo  d(.-^|)it(>  tlie  most  .an'fidly  (iii'ected  treatment,  vot  the  pructitinii.  i  iim 
du  a  I  It  d.al  to  relieve  the  distiY -mj^  symptoms.  The  stomaeh  ti  .iil,|,. 
uiid  the  .1  laiTliu-a  should  In"  attended  to.  lluMuorrhaps  are  lre(|nent  ui  I  n  ,• 
rarely  dangerous,  and  are  to  l)e  cheeked  hy  the  usual  methods.  Mttli  m  1» 
done  to  relieve  the  «lratry;inK  feeling  in  the  lel\  side;  the  pain  may  suinnii,,,. 
he  so  severe  as  to  call  lor  sedatives,  but  their  use  shouhl  he  delayed  a-  l.nm  a. 
possihie.     In  the  use  of  purgative  medicines  much  caution  should  he  ul,.,|v,. 

Hodokin's  Disease. 

Definition.— An  atl'eetion  charm-terized  by  progressive  hyporplaM:i  at'  i| 
Ivmphatie  glands  occurring  with  aiuenna,  and  .sometimes  uoecmipanicd  hy  il,, 
(ievelopment  of  secondary   lympliatic  growths  in  various  parts  of  ilic  h,„|v, 

History. — The  disease  which  now  hears  his  name  was  lirst  dcHiilicil  |,i 
ll.idgkin  of  (Iny's   Hospital  in  18;{2,  in  a  pa|)er  entitled  "On  8(.nie  Mnil,;,| 
Appearances  of  the  Ab.sorbent  (Jlands  and  Spleen."'      Morgagni  ami  (,ilii.|j 
observers  had  before  this  mentioned  cases  with  enlargement  of  the  l\ mphaiiJ 
glands  terminating  fatally,  but  the  aooinpanying  histories  are  too  niraon  J 
allow  of  any  judgment  as  to  the  nature  of  the  maladies  with  which  tiKydcait.j 
A  number  of  the  cases  described  by  llodgkin  were  undoid)tedly  e.\;uii|)ii>nt I 
tid)erculous  adenitis,  but  at  least  four  of  them  were  genuine  instance  ,,1'  wluJ 
we  now  speak  of  as  "  ITodgkin's  disease."     The  atVectioii  received  its  iiamJ 
from  Wilks  in   18(Jo,  when   he  .cported  a  series  of  cases  in  whicli,  t(ip'(li,fj 
with  aniemia,  there  was  enlargement  of  the  lymph-glands  with  gn.wtib  iJ 
the  spleen  and  other  organs.      Virehow  described  the  histology  of  lyiiiplhKuj 
t:nma  in  1845,  and  later  Cohidieim^  discussed  the  pathology  of  the  alVniiniiJ 
giving  it  the  name  of  pseu<lo-lenka'mia,  on  account  of  its  supertieial  iv-(tnl>laiirj 
to  leirka'inia.     The  studies  of  these  investigators  attracte«I  general  iittciiticm  i.| 
the   subject,  and    the   literature    is  voluminous.     UidbrtUh.i'vly ,  miiiiy  «kJ 
described  have  to  i)e  weeded   .)Ut,  a^   (he  alVection   has   been   iv;.    \v<^\s  m\\ 
founded  with  tuberculosis,  true  leuk:emia,  syphilis,  and    iienplaMni;'a  of  i 
lymph-glands,      r.illrotlr' endciivored  to  distinguisl-  these  growth-,  wlii.h  li| 
named  malignant  lymphomata,  clinically  from  the  local  non-infectiw  lyiiiiilmj 
sarc(    -.ta,  .stating  "that  in  the  former  there  was  no  invasion  of  the  |M'ii'laiiil 
ulart.,   ■('•■.  while  in  th<'  latter  the   new  growth  did  not   conline  ii-rlt'tn''' 
glatuts.        •."  ..les(  .■;,>ion  of  this  disease  given  under  the  name  ..f  wWu 
the  great    i^;.*'<'..h  clinician  Trousseau  is  so  accurate  that  the  all'erti.m  i>  nrnj 
often   lei-  yiv  '  tr  as  tiie  "  \-  ado-h'tikicmia  of  Modgkin-Trousseaii."     HanvKJ 
introduced  the  term  Ij/mph-athnih;  and  the  number  of  other  syii(iii\  moii.-Mnij 
used  is  very  great.     Thus,  Wilks  has  termed  it  aiiffiinia  lymphatica;  WiiLMioj 
and  R.  iSchulz,  "desmoid  carcinoma;"  Mur.sick  called  it  lymphatie  ea.licMal 

>  Truruiaclinux  Mnl.-(;hir.  Soc,  v.,1.  xvii,  1832.  '  Vi,rhwr,<  An-lur,  I!.l.  x  sxiii.  |).  V>1 

^  JkUriiye  zur  PathdoijUclwn  Hixtoluyif,  Berlin,  1857. 


JifUKiKLWs    />/.,/    ,,v,. 


227 

liiniik  ",.a,.|».xia  siiis  l.'iirM.ii.l,.  •"  » l>il.,  <     .1 

■\y  .lUus.  i,s  no,  „„,..„,„„,.„  in  An,...i.,, 
Etiolo«ry.^At,„vs,.neu..,„„,sM,llnw,h..'„.nn   ....ml     I     1        • 

.-i.<i"it.> an.i ,ii.; t .litall  (, : : "'";■''  ''"'"'■••  '""^^ -■■" '«•  -••-^"•i-i 

»itl.  tlu.  Jifmitrnv  of  no,lirkiM's,Ii  ....    V'    •    ""!""'"'"  •"'"•'l-'aint  hinw.lf 

I 'i'i'-.  i-v,.i..,.  H ,tt!:;;;;^;:;::;:'r-'-^;;;;''';''''-''''<-'^.'.^ 

^.l.e....v  s..v..n.I   i„sf:.n,.„s  n..M  in  whin  ,.;"";'"'  '"'*   "•"••-"'^• 
|li;inj:.'  lias  taken  pla.v.  '"''''  "'^^''''vatioii  mid,  a 

.vi,n„.,r  M,  persons  „„.),..■  /;„,v  v,,„-s  of  a.;      T L    ;    '•"'"'.'■:'"■"'  <l'«'«'".-"s 

\: '; : '^■'-'■"-""'••''i".^:::'ti,s-;::;::;::r";:r'- 

|.i;,ii..„.  ,„,„„,.  ,„■  „,„  ,n.,,,,  „„;,  ,,;„:  :;:z::u::zz!':  r' " 

|h  KIw.iri,, 1,1.1   ,■„„, „|„|    I, I      ..  I  '■"  ln^   r,.i,.,      ,|,,,.|.,|,,,| 

J tful  ,.aso  was  sottl.,!  onK  bv     . .         •  ^''<'   •'-—••'<'...  tl..  ,lia,n,osis  in  a 

|rf.  Lnlli  i„  n.,n,..  "''"'  "^  P'^^"^'«-l^"l<a>n.ia  an.]  lound  tul.c- 

Jlit't;;:;:::;:;::;:;';  -r  ^ ••-  -n-o^o  eases  i. ..,.. ,.... 
H-i'.. septic inf;:;;;;*  ^ :;;;:' •; 7"? -'^ '^^ t"-'-'-'--- -Jt^. a 

^'".  my  uanls,  ha«  n.a.l,.  ont  ....  t  in        1      V      "^  "''  ""'  "'^^'""^  ••^'  ='  '"^'^'^ 

l-nntos  wl.iel.  possiblv  stan.l'in  a  r,ns..| '  J        '  ''"/'"""^^  •"«y  '^^'  ani.nal 

l-.vd  .naterial  fn>n,  Another        .;      "^''"iV?  ^'""  '•^^•^••^-"-       f-ter  l.e 

""l"-,lnl,.s  in  tluM„testi,la  ;    iV  ;    r^t'    '"  """"^  ^''^  ^="""  '>'"''- 

J"'l'"-"=n I  nn-aute  partielc.  wi  I        "l.    ^'""'^ '!"^''^^''""«'"^*'"' "f-p.-ot-plasn,, 

I  "'"■•' «itl,  ha.n,atoxv]in  a„<I  csin   and  w  ,     ,     V,    '^'"  .'^"•'l'^^  ^^™-  ™sily 
•.M».  //o;,X/«,s  //„./,■,,/  y^^,„,,,^  ,y,j^;  ^^-  '■"^■'  !••  II'-^. 


I    .(,< 


n 


i,  n 


1  I 


228 


DISEASES    OF    TIIK    liLOOI). 


'i 


if 


wa.s  suiToiiiKled   by  a  zone  (if  protoplasiii,  and  tlio  intensity  ot"  tho  stu mnjr 
was  not  so  jri'oat  as  in   tVajfnionts  ol'  iiiiclci. 

Morbid  Anatomy. — Tiic  patlioloj^iral  clianj^cs  fltund  at  the  antop-\  .,  jij 
vary  afconlinu  to  the  portions  of  tiic  lymphatic  apparatns  atfw'tcd.  v-  ;, 
rule,  the  lyinpii-glands  are  soft  and  clastic,  though  in  sonic  few  cases  tin  an 
tongii  and  firm.  In  an  advanced  ease  the  glands  will  be  seen  fused  to-i  t|i(.,. 
into  huge  bunches  as  large  as  an  orange  or  even  larger.  Should  the  p;ii(i,t 
die  in  the  I'arlier  stages,  this  matting  together  of  the  glands  is  not  so  c\  'lent, 
as  at  the  onset,  when  the  enlargement  first  begins,  the  individual  glaii'i-  ar,. 
isolated.  As  a  rule,  there  will  be  found  to  have  been  more  or  less  eonni nivi- 
tissue  proliferation  about  these  glandular  tumors,  with  thickening  of  the  llliidn. 
capsule.  The  cases  in  which  the  growth  j)erforates  the  capsule  of  tin  -land 
and  invades  the  neighboring  parts,  such  as  the  nnisclcs  or  skin,  liasc  Ww 
placed,  as  we  have  said,  l)y  liillrotli  in  a  separate  class.  On  cutting  iin.i  im,. 
of  these  new  growths  the  surface  will  be  found  smooth  and  the  sul)>taii(r  nf 
variable  eonsistence  ;  sometimes  it  is  soi't  and  juicy,  while  in  other  caso  it  mav 
be  firm  and  drv.  The  tumor  is  nsually  grayish-white  in  color,  and  tlio-i  caM- 
in  which  caseation  has  been  reported  were  probably  not  eases  of  psc^ucL-li  iika- 
mia  at  all,  but  rather  a  tuberculosis  of  the  lymph-glands.  Pyogenic  pinci-M. 
sometimes  occur,  especially  if  the  growths  invade  the  skin,  the  sui)|imatiiiii 
here  being  of  course  due  to  a  eoinplicatiug  infection  with  eoeci.  I'u~  ruinia- 
tions  in  the  deeper  sets  of  glands  arc  rare. 

The  glands  of  the  body  most  frequently  affected  in  this  disease  luv  tin 
superficial  chains,  particularly  those  of  the  neck.  Not  infrecpiently,  at  ilif 
post-mcrtem  examination  one  is  able  to  trace  the  cervical  glands  as  cnntiiiiicii- 
ehains  running  down  along  the  trachea  and  large  vessels  to  join  the  axillan 
and  mediastinal  glands.  \ext  to  the  cervical  groups  the  axillary  glamU  an 
most  frequently  attacked,  and  then  the  tnnior-niasses  may  extend  in  nnilcitln 
pcctoralis  major  and  minor  nniseles  and  backward  beneath  the  M'apu'a.  hi-, 
ot'ten  such  masses  are  formed  from  the  glands  in  the  groin.  Those  rax- an 
])articularly  interesting  in  which  the  glands  in  the  thorax  are  inudi  ciilaiirnl 
and  press  on  the  vessels,  or  even  occasionally  perforate  the  sterntun  ami  apiicu 
externally  as  a  tmnor-like  projection. 

The  retroperitoneal  and  mesenteric — in  short,  any  of  the  lyni|ih-i:liiniL- dt 
the  bodv — mav  be  involved.  The  diagnosis  when  the  abdominal  gland- nlmn 
are  implicated  is  of  coin'.-e  extremely  ditfieidt.  I  remember  when  in  (Idinaiiy 
some  vcars  ago  seeing  a  leading  gyna'cologist  perform  a  lapamtdiuy  lln'  in 
abdominal  tumor,  presinnably  a  myoma  of  the  uterus:  the  inci>ion  rcvdilid 
masses  of  enlargcil  lym|)h-glands  adherent  to  tlu'  uterus  and  adncxa,  tliciiiM 
proving  to  l)e  one  of  Hixlgkin's  disease. 

The  histological  changes  in  the  glands  seem  to  consist  chiclly  iA'  a  liypw- 
plastie  proliferati*)!!  of  tlie  cells,  t!t(>  rcticnbnn,  as  a  rule,  imt  brinu-  thiikim-J. 
The  normal  relation  of  the  lymph-paths  are  in  the  early  stages  inaintaincii, 
and  it  is  oidv  when  the  growths  have  become  large  thiit  these  aiv  (listiii'lnil. 
The  bands  of  reticular  tissue  vary  in  thickness  and  density  in  dill^  >  at  places 


f  the  st;i';iiii;r 


le  sM])|Mir;iti(iii 


HODdKI.Ws   I)  IS  I :  ASK.  oo.) 

,n   k  spleen.  :  ,„  .5  por  cvnt.  of  tlw  «...  tahula.-,!  l.v  (iow...  the      .-  .    o,  o 
Hilar-cmci.t  of   ths    ()r..-aii    and    in    -,(!    .>„..         .    .\'  i'»  it  \\a>  ,>oni(; 

iii^'  '-«A,  (1.0  iv,„p I ,1,,  „,  ,|„,    '       "";    ""  i""«-"'"iT»«-, 

'V.™ - ->ita'.v  ..iiiou.  in  ."ilr: ,';:';:;;:;; j::j"    -'' 

Ite  lung.  ,„-o  ,x.-oasi„„»llv  :„v„lv,,l,  ,.i,lK,.  I,v  ,liaH..(  i„g,,,„.,|,  ,■,,„„  ,|,e 

i.»-..»i  k.in,v.  Ti,o  .ki„  i.  »,„„„,„  „,..  „,,  .,nv„,pi,™,„ ,;;',' 

■ns:  .  ,.  lal.o,.  o«„^,l  „„„  of  „„,  „„„„,,  „„,|  ,„^,,^,  ,,__,  _  '    A 

,,,,,,,,1  c.v„„„„M,,„,,     A  ,,«.  i„  ,v|,i„|,  ,1,0  l,o„,.,.,„„„,„  „.„:„.  ,„|  , 

i.,.|H™  ,l™b„l  by  WK.g,„„|,.     TI,o  ™,„,,1  „o,-v„„s  sv»,o,„  ,1,0  1,   r 
aiiJ  !i.lrviials  iiiT  i-jroly  iiiviidod.  ■    "-'"' ""^  B'mtJl", 

TI,o  ,IUHl„„io„  of  ,l,e  ,„ota„a«,  „m.*i,a,o,  ,l,o  a»«,mpei„„  „f  eho  oo„. 
v«a.uv  ol  tho  oxo,t,„g  age,,,  i|„.o„gl,  „,„  |,l„„,i.„„„,,,„     '     -  "'" 

SsmptomatoloCT._S,„«  at  p,.osc.„,  wo  a,-o  (m-cwl  to  i„o|„,Io  ,„«lo,-  ,l,e 

.r ,•.„,„„.„,,  appi,o„,io  ,„  all  „,„,.  ,,..  ,|,„,|  „;      .i,,,,i ,'";.;; 

1-r :::: «:,:::::,!:;:  ft : - "" ■ '"^^ "'™  ^'^^ 

■■"l»«li;„.,ixvoa,^     1,0     ;,   I       f' ''■",'"  ""■  "''ill",  "-biol,  i,a,l  l,„„, 

,,, ,,, ,;  8,;  „.","•  "'"■""'  «'""'i«  '•"  ti'- «"-  -lo.  \vi,o„ 


i  ■! 


I  ■ 


^f 


iff- 


280 


DISEASES    OF   THE   BLOOD. 


by  physical  examination.  Fn  a  case  observed  by  Ross  of  Montreal,  (oi.  \lij,,|| 
1  made  an  antopsy)  in  which  redema  of  the  feet  and  lancinating  pain-  ,i;  [j,,. 
distribution  of  the  nerves,  occurrinfj;  early,  were  followed  by  complcti  paia- 
pleijia,  we  (bund  a  jrland-mass  pressing  on  the  spinal  cord.  If  the  luillmv 
glands  be  much  enlarged,  there  will  be  (vilema  of  the  hand  and  arm  (iMm 
venous  obstruction.  The  inguinal  glands  sometimes  form  large  tiuuoi  uhi,.], 
occasionally  become  pedunculated. 

Extraordinary  symptoms  from  the  pressure  of  intrathoracic  gland- mv  n; 
times  met  with.  In  a  man  who  still  frequents  my  clinic  the  superinr  vi.na 
cava  is  completely  obliterated.  Tiicre  is  considerable  congestion  of  tii!' hcul 
and  upper  extremities,  but  a  fairly  good  compensatory  circulation  Im..  I,,,,,, 
established  through  the  superficial  veins.  The  chest-walls  have  been  ciiiivcmd 
into  a  huge  felt-like  mass  of  dilated  veins,  tlie  latter  emptying  into  two  laivf 
trunks,  the  dilated  epigastric  veins.  Occasionally  he  has  an  aii;i(k  of 
phlebitis  in  one  of  the  smaller  veins,  and  here  and  there  small  plilcijoliths 
have  been  formed.  One  day,  while  doing  heavy  lifting,  he  had  an  attack  i.i' 
hiemoptysis,  losing  about  a  ijuart  of  blood — an  accident  which  relitvwl  tli 
congestive  symptonis  for  some  little  time. 

The  retroperitoneal  glands  are  more  fre([uently  enlarged  than  the  nuMn- 
teric,  and  in  thin  individuals  the  nodules  in  the  abdomen  can  be  tiukIc  (.m, 
Along  with  tlie  afl'ection  of  the  abdominal  glands  there  may  be  wtll-iuiirktil 
bron/ing  of  the  skin,  as  in  Case  IV.  of  my  series;  Fereol  described  a  simiiar 
case,  and  Crocq  suggests,  by  way  of  explanation,  pressure  of  enlarged  ol;,ii,l, 
on  the  suprarenal  capsules. 

The  variation  in  the  rate  of  growth  and  in  the  size  of  the  glands  at  (liHl.r- 
ent  times  is  astonishing.  Where  they  have  been  large  they  may  tliniinish  in 
volume  or  even  entirely  disappear ;  a  rapid  diminution  in  the  size  oft  iKMrlan,]. 
shortly  before  death  has  been  frequently  observed. 

The  spleen  is  often  sufficiently  eidarged  to  be  easily  palpable  in  the  kti 
hypochondriinn.  The  thryroid  is  occasionally  affected,  and  in  rare  iiistanco" 
the  thymus  as  well. 

The  patient  may  go  on  for  a  long  time  complaining  of  little  else  tliaii  liie 
inconvenience  resulting  from  the  presence  of  tumors.  Sooner  or  later,  tli(in;.'|i, 
the  auicmia  and  the  cachexia  gradually  appear.  He  begins  to  feel  iaiionid  ainl 
disinclined  for  exertion,  whether  mental  or  physical ;  oedema  of  tiie  leirs,  luatk 
ache,  palpitation,  and  dyspncea  succeed.  The  blood-count  is,  as  a  nik',  iifi 
strikingly  low  ;  in  oidy  one  instance  have  I  seen  the  red  blood-('ur|iii-.(le,<  >iiik 
lower  than  2,000,000  per  cubic  millimetre  and  often  there  is  no  ihrmiH'  ;it 
all  in  the  nundx'r  of  red  blood-corpusdes.  There  is  no  extreiiie  pdikilnov- 
tosis  and  the  lencocytosis  is  inconsiderable.  In  tlu,"  diiferciitial  eeiint  ilie 
lymjihocytes  aj)pear  to  be  relatively  increased.  Where  there  i-  a  inarkcil 
lencocytosis  with  a  i)r('))ouderance  of  lymphocytes,  we  have  tn  tliiiik,  4 
course,  of  a  lyujphatic  leiikiemia.  An  occasional  nucleated  red  ■clj  (umiiid- 
l)last)  may  be  fiiund. 

The  jialpitatiou  of  the  heart  may  or  may  not  be  severe.     ( >ii  exaiiiimitinii  j 


HC)DaKIN\S  DISEASE. 


231 

nninnurs  mav  usually  ho  hoTi-d  r.,.nr  fi  i- 

only  functional  in  chLct  T  "^^        "'''""  T'  ^"'  ^^^^  «-  P-bably 

or  !>'-  clue  t<,  pressure  o  who  T     ,  '  ■^'*""'  '""-^'  ^^'  ^'"-^  "^''^  "^  ^ho  ana-mii 
.ea.nu.of  thoLS      ^,   ",  2^^^^^^^  oocas-onall,^  there  is  hvdrothorax  or 

^■-  will  he  ..uu^  eve/iute::  r;;;  r  '■=';:^:^tr'r^  '-^'^  ^''-  ^^^^ 

-■•-■I'  more  often  has  a  recurrent  tvne      In  'c-.s  •       """'""•-•■^'  '^"'  ''t 

-"-•l-Me  a,ue-likeparoxysn.s  at' Lvi-^^  ini^v^  xir"'::  '""  r'^'"'^ 
.iiav  persist  ibr  weeks  or  even  n.onth.  h-u-o  J  \  ,•  ,  '  ""'""''''  '''''«'' 
i.l^'l,tho  «>nner  ohserver  b;;^  h  J  :  :.^:.:;t::f  ,k  T  l' ^'^^^'^  ^'"' 
"--"*«-tions  disease,  since  durin<.  a  period  of  n  "    'l'««>vero,l  a 

:.rtarks  of  fever  lastin-.  fron,  t.-n  fn  /       T  '  '""""'■^  ^''"  P'^^'^"*  ''a<l 

•o.'  ton  or  eleven  davl  '"'"""  '^'>  ^^'^"'-'^'"^  ^vith  apyrexia 

Usually  the  digestive  symptoms  ar.>  not  nnrl-od   .Ifl        i    •      , 
«l.ic^i.  there  is  extensive  atrophv  of  tl     '     [   '    L        7'    '"  *'"''  '''''  '" 
.'-•.ect  to  find  serio..s  disturb.neos      Tl  ^'■'^'^-"'  '''^^'""'   ""•<'"'^a  one  woul.l 
ii-   is  slightly  onlar  J  ^"  ":     ^''T  '"^  '"^  «  ^'"'^  »«-tos,  and  the 


^li  iiie  naso-pharvnx  which  Inve  oiihui''^.'"  ""r'^"'"*  '^^  «^'^""id  S'-owtl. 
•"ilatoral  ituH.u  J  ^m  "  ^     '1'"  "'''"■^  1"  ^'"^  ^-^-''"-^  tubes. 
•  '^y  'ii'atatiou  of  one  Zl:::^::.^^^ .^"^^^^^^  ^'-ving 


Oi!  cxainimitKin  I 


1'"  -„.  In  addition  "  ^  i"  •  fi  '  "ll^r^f""  ^'  ^'"^  ^''^^'^'  '^^ 
--^'■^  -^1  the  bronzing  hd  1  :"",^*'"'  ^'^'"  ^>;  'y-P'-mato.. 
■ionallyan  intense  an<l  tr!^d>le^me^J^„  'h'' ''""'r'"'^'' ^''^'"^  ''  «^^«- 
So„H.tin,os  there  is  albunnnuria    '    I         .     '^  '"'  ""'"'"*  *''  ^''''J'"''"'-  '■^^^''• 

.•l.:.<.s  into  the  skin  and  Z::::\:ZT ^  '''']  "'T  ''  ''=^'"'"- 
'""•  '••■"'arks  on   Leukaemia  of  the  .!  ^    '""'"  '*''"™'^y  '^P'^'^^"  i» 

1-  1«-  .I-oribed  byt       j:L^  "t"-  f -'"-'-'<-"ic  an.mia  which 

lii^tory  uf  ehancro   can    be   obt-iine,!    ;i  ^M>'"lis.     hven    when    no 

.v.ard  to  ulceration   of   L       r    t    k   "   P^'^-ont    nn.st    be  ,uestione<l  with 

--'  •>■■'■  ^>^ouid  ascor;;;:, ;'  i  "it  1 1  r  1="^  -''' ' ' '-  ^^ 

'iifentiation   from   tuberculous  .uloni  ^  ■  '".soarriagos.     The 

•I'ief  points  of  distinction  a  i'^  "llf  ''T'   ""^  '''^-It.     The 

'-i'"l-vonng,ar.,l  involve    the  ^f'''''^"'""'^  '"^^'-iti.^  i-^  more  com- 

""-  nunnng  altl.g  the  ^      :  tT''- 7^7''  '''^'""'^  "^^^^^  *'- 

«l'c'.v,.s  those  latto^-   are    ,no       f.f     '  >"■     '"'*^"''  "^  ^''^  '^to'-KMnastoid, 

,|.,„^,^^^  more    frequently  the  first  attacked   in    Hod,d<in's  • 

''"'  ""■  -^t  importan  "i:^:;  i',"  t  :;  T'^  "''?'  ^''""  '^^"  'y-'Pl.-lononu,. 
-l'l--..-a  fij„,  rare    "  ,   •  ;lulo       .  T'"'''  ^'^""'^  ^^-'  ^•> 

'•"'^''"'  ""  -'™o„s  size. '  ^Ve  n    C  ;    1':r'  T'"'''^  ""''^^^  ^''^^'  '•^'- 

"'"t-i>"'<'  of  su.h  a  nossiblo    .     t  '  "'P''--''""'-^  "^  the  nook.     As  an 

'"'•>-«-"■  «.■■»'';:*  ";,:™r:;:,;;::;'v'-  •^;"';»™^.<-:  a  „„.„  „f 

'-"'-'■ • '^ ----;-Xtsi;;;L;si^ 


■^i 


Hi 


I  , 


232 


DISEASES    OF    THE   liLOOI). 


f 


witli  irregular  fcvor  ami  cliarrha>a  :  a  diagnosis  of  Ilodgkiii's  disoasc 
first  made,  but  was  ai'torward  given  up.  The  oeourrc^nce  of  ague-lik.  i,;,.. 
oxysnis  and  of  recurrent  attacks  of  fever  is  in  favor  of  psendo-leuku'iin  ,,  but 
there  certainly  are  cases  in  which  it  may  be  impossible  for  a  time  to  i,  :i[<,.  , 
certain  diagnosis.  Where  the  glandular  enlargement  is  localized,  it 
oidy  justifiable,  but  also  advisable,  to  remove  them,  when  the  diao-iic 
be  cleared  up  by  microscopical  examination. 


at 


lint 


The  disease  is  to  be  distinguished  from  genuine  leuka;mia  bv  the 


aiiiiii- 


ation  of  the  blood,  which  should  be  nuule  carefully  in  tdl  cases. 

Prognosis. — ITodgkin's  disease  is  in  the  long  riui  almost  invariablv  a  i;ii;|| 
affection.     There  may  be  marked  variaticjus  in  the  course,  distinct  cx.Kri'ha- 
tions  and  remissions  being  characteristic,  but  the  cases  of  complete  and  iicnna- 
nent  (lU'c  are  rare.     Where  the  gland-involvement  remains  localized  fur  a  luii" 
time  and  docs  not  extend  to  other  groups,  we  may  expect  a  loiin-  pciioi]  ,,f 
comparative  health,  but  when  the  ghnid-tnniors  are  multi])lc  and  aiv  tii  be 
found  in  different  regions  of  the  body,  and  especially  in  those  eases  in  wliidi 
the  cachexia  develops  early,  a  fatal  termination  may  be  soon  expected.     Drati, 
comes  in  different  ways,  but  most  frequently  it  is  the  result  of  tin    ■j:n\m] 
asthenia:    the  patient   grows  weaker,  and    perhaps    becomes   emac ,  kI  ;  tli. 
dysphiea  and  palpitation  increase,  the  legs  become  sw(jllen,  and  at  iliu  (inl 
perhaps  there  may  be  hydrothorax  or  eedema  of  the  liuigs,  with  heart  t'ailinv, 
Of  course  death  may  occur  from  pressure  upon  important  parts,  as  in  tli(w> 
cases  where  the  trachoo-bronchial  groups  of  glands  are  much  eidai'uvil.    Tin' 
occurrence   of  high   fever  or  of  hajmorrhage  is  of  grave  import,     'flic  .iciito 
cases  may  die  in  a  few  days  or  weeks,  the  chronic  lasting  sometimes  maiiv 
years.     Two  of  my  cases  (l'm\  from  general  infection  with  the  stl•(■)lt(l(0(^l^ 
pyogenes. 

Treatment. — Besides  hygienic  measures,  the  internal  admini>tiatioii  n|' 
arsenic  is  certaiidy  of  value  in  some  instances.  As  soon  as  the  (li;inii(isi>  Ii;h 
been  established,  the  patient  shoidd  be  given  Fowler's  .solution  after  uw.iU. 
well  diluted,  the  dose  being  gra<luidly  increased.  If  benefit  is  to  In'  ilcriviii, 
the  arsenic  must  be  pushed  until  its  ph;  siological  effects  are  notiirablc;  if 
these  be  troid)lesome,  it  may  be  necjcssary  to  discontinue  the  niO(liiiii«>  liim 
time,  returning  to  it  later  when  they  have  passed  off  The  injiction  „i' 
arsenic  into  the  affected  glands  by  means  of  a  hypodermic  needle  li;i<  lim.i 
recommended,  but  \\v  shoidd  be  inclined  to  regard  it  as  a  wholly  imiMivssirv 
procedure. 

When  the  case  is  seen  early  and  only  a  few  glands  arc  eidargtd,  witlmiit 
any  evidence  of  increase  in  the  size  of  the  spleen,  the  question  of  exeisinn  ,,t 
the  nodules  may  arise,  and,  if  there  be  also  no  cachexia,  I  coiisiiler  it  goml 
practice.  Xot  oidy  does  the  diagnosis  become  entirely  cleared  up,  hut  tlicp' 
may  perhaps  be  a  chance  of  limiting  the  progress  of  the  disetise  in  tin's  \v;iv, 
and  at  any  rate,  with  the  improvements  in  technique  possessed  U\  nuideni  mi:- 
geons,  the  operation  is  trifling  and  attende<l  with  very  little  danger.    Smvical 


II<>lHiKIN\S   DISEASE. 


intcnnl  admi„i,stration  of  iodine  an.l  of  l.o  .-7  ^'f''""""^"'  ^''^^'''t-  The 
-n  to  be  of  ..,,,eater  .m^^^ :^  ^^  Vot...uun  wo.dcl  not 
Imo  .een  good  results  following  the  use  If  ''"'"'"*  '^''''^  *''«*  ^'"^v 

-on  the  arsenic  is  not  well   h.^  Zlt^'""    T' '"''  ''''''''''  '-'  -v 

U^f  roconunends  inunctions  o '"  ^":^^^  7'^' "^^  ^--  ^  ^rial.     y,", 
Everytlu-ng  possible  should  be  dfne      ^^    ""^V'""""^'  galvanis.u. 

-''  -•'•'  -tntious  food,  an     nvi  ^^       r?^T  ''';'  ^^'•"'^'^''  '^^'^l--  Patient: 

hnlof  tonics  such  as  cjuinine  T  Z  do  T'l  ?'    m"'"^"''  "'""'  -'■^''  ^''« 
-Ha'v  to  the  in,lividual  affect'l      Chal      f         " '^  ''  *'"  ^""^^^''^  "-1 

l»ell-c->.Klucted    establishment    where    hZfnth     '"'  ««^"«.  «  course  in  a 


/ 


C  x-  X  y  v'i 


|i    \i 


;  i 


On  Sporadic  Cretinism  in  A 


merica. 


BY 


WILLIAM  OSLER,  M  D 

PKOKESSOR  OF   MEDICINE   IN  THE  JOHNS   HOPKINS   UNIVERSITY 


CHIEF  TO  THE  JOHNS  HOPKINS  HOSPIT 


AND   PHYSICIAN-IN- 


AL. 


.'Si 


PROM 


THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 
November,  1893. 


M 


r 


lil  I  H 


Hi 


J''.Mnirl|.,|  (Voiii  'I'll,.    \ 


'iicricMM  Jen 


iriiii/ 


'I'llif  Afwii,,, 


•^••i'-'iKvs,  NovcNil,,.,',  |>;i;i. 


"■-•"-"t"^n  group  „n.H,,,,,,.  ,     I'T'  '\ —al.K- ho,..  i„  u.e 


Ardation   I.e.  „Wn   „.;T'?'"' "'"'"''''' •"^'"■•'^'•'^• 

™,,„A.iult  Life  i„   \\'.  uj-  a  :\,'V'  ''"'"'"•'  ^'"'''  ^^''pe.- 
1^".  ".  a  fuller  .le^cTipUo,.  of  „k.  2  .  ^'""•'>- ;^l'i"-'-^'""l    Ly  Onl,  i„ 

'''•■;-•'-'  «^"f-  ..(•  ti.e  ,hv.-oi,i ,  n  w"; '"  "'•"  "^  '•'""""•"-  -th 

-'■''-'"  io.,n,l  hy  ,lK.  s.!..  ol,:;    ■    . T  "'T'"'^-     ^^-'  -nKu.kal.le 
;■'■'"'"!  ^-^^'^  "n„tal  ..x,irp,,i„„  „      ,'    "■^■^"':""  '""'   K'H.luT,  ,o  foil,.,, 

-:1--,  ,luvw  a  lloo-lof  ]i.|„     '     If  ?."^  -'  -/-W-nental  „n.x- 


^'---'•iHion.  i.  t,„  ooounvn,     ;  ,        :'"^'""  ''"'^  --no,,  to  all 
'"-'^•'"J^  t'H3  annihilation  of  ,he    u t  ^    /"'"^^  "''  "'"  "l-'''ttions 

,  "--^  ''-i  at  n.v  dini.  ni      ,       ?""  "  ''!^'  ^''>'''-'  '-'1-"^ 


';^-  P>-e^e.ne.l  at  this  .....tin.   I  ,   ",     j"  ''  ^"'^'^^f  "^--yxoden.  w. 
'•^l--'  '--  nnule  i.  i  J,,  „„„„  ;,     . ''     •''-«-  >"  this  ..ount.^..     Th 


ne 
as 
r- 


'  "™''l«^'l'"rtMheAss„oi,i 


'"'"  "  '•"■^•'•"1  search  of  tht  1 


iferatureso  far 


'»-.'""  ••!  ,i  f  uinini|i,.L.  ,,i  th,.  i-ii,  ■     ,       ■'■•^"  i-i'i---.  Mav,  Imu 


''■  '.'i''     l.oii.l,,,!,  isss. 


;         I 


I 


ns  it  rclntc.*  1..  the  United  States  aiid  Caiuulii,  and  upon  in(iiiiries  ninde 
(if  tlie  siipeiinlciidcnt.s  of  the  Asyhinia  for  the  Insane  and  of  fnstitu- 
tions  for  Feel)Ie-niin<led  Children  thnmyhout  tiie  eountry,  as  well  as  of 
many  friends. 

As  nuich  niisiinderstandiiij;  vx\Mh  nn  to  the  exaet  (h'finition  of  a 
cretin,  iihistrated  by  the  fact  that  at  least  one-half  of  the  i)hotoj,'ra|)h.> 
sent  me  from  different  institutions  did  not  belong  to  this  type  of  idio.'v. 
it  may  lie  well  to  define  somewhat  earefiilly  the  precise  eonditions  t,. 
wiiich  this  term  should  be  ajiplied.  In  the  first  place,  there  is  no  essen- 
tial ditlerenee  between  the  eases  occurring  in  large  niimiiers  in  goiln.u-. 
districts  and  the  sporadic  cases,  The  term  should  be  limited  accurate!, 
to  a  form  of  idiocy  associated  with  changes  in  or  ab.sence  of  the  thvn  id 
gland.  Tile  following  .statements  are  i)ased  upon  the  recent  articL' (,;' 
Horsley.'  Tlie  important  factor  is  the  loss  of  the  function  of  t!ie 
thyroi.l  gland,  wliether  this  results  from  congenital  detect,  progressive 
Jitrophy,  or  coarse  changes  which  gradually  annul  its  function. 

1.  Cuni/enltal  crefinimn  is  rare,  and  is  usually  associated  with  absemc 
of  the  thyroid  gland.  The  chiM  rarely  lives,  but  the  changes  presents! 
are  sufficiently  distinctive  for  diagnosis.  The  supra-clavicular  iiitty 
tumors  are  well  marked  and  the  skin  generally  is  ih-k  and  in  folds. 
The  lind)s  are  short,  the  epiphyses  swollen,  while  the  s-iafts  are  mu,li 
cssified.  The  skull  is  b>-oad  and  short,  the  sutures  ojien,  and  the  liasi- 
8j)hen()id  junction  is  prematurely  o.^sified,  a  i)oint  uixin  which  Virclmw 
laid  great  stress.  This  congenital  variety  may  be  difficult  to  distinguish 
from  rickets.  Degenerative  changes,  slow  over-growth  of  the  fibrous 
tissue,  and  a  myxcedematous  condition  have  also  been  met  with. 

2.  A)ile-tHital  and  mbHiquatl  n/oir  tlrrf/njiiiient  of  crcl!ni»m.       Ihie 
the  changes  ajipear  to  have  been  initiated  during  fretal  life,  l)ut  iiie 
slight  and  scarcely  noticeable  at  birth.     "  The  infant  shows  no,  or  very 
slight,  signs  of   intelligence,  but    the    physical  signs  arc  less  obvioii.^. 
According  to  some,  the  majority  at  birth  have  a  goitre,  usually  of  about 
an  inch  in  diameter;  the  i)ody  is  large,  with  disprop,,.-tionate  head  and 
hands,  and,  what  is  more  important  still  in  connection  with  the  similaritv 
to  myxa'dema,  in  many  eases  the  subcutaneous  ti.-^sues  appear  ledciiia- 
tous ;  occasionally,  according  to  the  severity  (jf  the  case,  there  is  also 
non-development  (»f  the  facial  bones,  a  flattened  nose,  giving  a  stii|iid 
appearance,  and  a  large  thick  tongue.     The  neck  is  short  and  thick. 
It  is  obvious  that  under  these  circumstances  we  have  the  same  condiliuii 
as  that  described  ai)ove,  only  much  less  severe;  the  further  history  of 
these  cases  shows  that  the  destruction  of  the  thyroid  glan<I  contimifs, 
and  the  symptoms  develop  into  the  worst  form  of  cretinism,  about  lo  l)o 
described."     (Ilorsley.) 


I  'liilic'.s  Dicti.mary  „r  r.',y.:li..lMi;ic.il  .Mudiciiii'  :  iii'i.  •■  Crutiiiisin.' 


Mm^ 


^->n.UT8  of  .ponuli,.  ,.n,ini.H„,  I,,.].,,,,  to    I.      r   ■        ""''"'■"•■  "''  "'''   '■"■ 

^''-  -"-.nark.,  lordosis,  ..  „,..,  ^L  ^  :""'  ""''•  ""••"  '-"^ 

'■"""H-r  the  neck  is  .shorlen..,!   .1,,.  1  'M'>'on„n..nt.     I„  like 

li|.«  thick,  an.l  the  teeth  ve../    n      .f^         "'"T''  "^^  ""««  '■"' -'.  "- 

'"-«  clear  hecon.e.  thiek.    |,e  vX^     ' /'^^  "''1'     ''''^  ^i'-'''-  '' ' 

"■"•"'^•-'^""'-'v isph.ei.,  tost., ;;;  V  ti:t:;:  "^  ^'""r"-''""""^' 

'•""'e«  scanty  an.l  thin.     There  is  u     l        T  "'""'■"''  ""'  '""''■  ''«- 

..eoim  tissues  have   a   pecniiar  kin.l  of     ,'""  "'""""'"=  ""^  ''"'"^"'«- 

--.  -   .0  speak,  soiil,  o..,en  t  ,;  :X  '"'  "''"^'•'"•''  "^  "'  "'-'^ 

tisMies.  <ui|);yinfr  the  connective  fibres  of  the 

"The  condition  tJitis  i)r„flii,.„  1  1 

'^- '-"  '"•  «itee„ ;:;:::'  r;*;  -  -  ''-^>.t  -."Hy ..  the  ...1  ..r 

i-as  attained  -UM-lete  .leveh,  1  ',^1  ""''!•  '"'  '^""^>-^''^^'  -"'^  '^ 
■^tationary  un.ii  death.  Hence  .,  """r,  ''"'"'''  '"^^"'"'■"■^  l'--'-'"y 
--  |.resente,l  i«  that  of  a  ,;;  tlT  "  .'"-^  ^'"  ''''^•^'^■"'  "I''-"- 
--'-•'y  .i..<.  not  advance  C^,  tl7^  ^u    ";'^""*"""'  '••>"'"'-» 

'•"  '!"•«  paper  belong.  i„  ,i,i«  division  "'       "'     "'"'"''  '"''^  ''""sfated 

Tlio  adult  condition  of  cretinisn.  ■,  •    ■        • 
"I-i  si-vly,and  have  reac  'irTV'"""  "''"''  ''"^^'  ■'--'■ 

"-.  i^  very  ciu.racteri.tic.  Th  '•  ' L  ^7"  '"""'^  "'•  "''^^>-  -'<' 
r^'"^'"-^  "  '-».  degenerate  1,        p  n'  'T'''':'  /'^  '^   "^  '-» 

"'  •^'"""■^^  '""'  ••'•"•'i.sh  in  appearand  t;,!  "'^^"^■^■^"ally  ;  .hort 
excml  that  of  a  chihl  fn.n,  IJZT  "  ''"'^''"  "'""""y  d"es  not 
■•-.'1^  -n,etin.es  brown       d  "f.    .7?"  r""."'-     '^'"  ^^^"'  '"«  <>^'^^n 

■""ii.s  tissues  are  much  infilt,a,ed  si.  »l,  .  ','"  '"■■"^"^•^■■*  the  subcuta- 
''-'•  ■^.'Pm  clavicular  folli;  l,  .'.^  ;  ^  ^  ''"'  '"'^  '  ""•'""■^'>'  -->' 
""■  ^•""■""•n.  The  hair  n.av  W  tud  "'"  ."'■'•''^"'*'"""<'"s  characteV 
'"■'"'•  "•-  i"  adults;  but  .  ne  u'/"  "  T''^'  """""^'^  ^"  ^''^ 
"-"'•■and  on  the  pubes  T  f'  ,  '"'"  ""'"  "'^^  ^'•"-'^  '»  *'- 
Hi'v.  though  -metin,esi„tlLs2.  ;:;'"  "^/"^^^''^ ''"'"e-  and  stu- 
J'"'  'il-  are  broad  and  thick  ad  "  ''  ''''''^'''^  '•""'  ^■"■■li"','- 

•--  ^'--^trilswide;t^;  1.^^'!'"^  l''^  "^  "^  '"-1  at  t^ 

''^^--  -^"  the  .u.o.iabiait<;  'V ::  :'i  ^''^^^.T'!''''"^""^-  ^"«"^' 

■-'■'"^""""«  present  strabisnu.s.     The  e veild  '  ^-'^''y  «"Parated  and 

*-  *'•>'''"'''  '"■'-^  "ften  .edenmtou.s.     fn 


'■'I 


,  > 


1 1, 
1.': 


advaiur.l  .asos  tli(iii;;li  tlicy  hc,.  thingH,  y.'t   they  mcc  willimil  tiny  iiitclli. 
Kt'iice,  uikI  the  t'xpnwioii  of  tlie  vyv^  atlils  v.iy  nmcli  to  th,.  iiiipa-^ivf, 
iiiimohilt'  asptrt.     T\w  Um^w  \h  often  thick,  larp',  and   may  constaiillv 
pnitnidi'  from  the  mouth.     Tlie  j<kiill  i.s  larv*'  in  proporliotito  tlic  iiody 
and  to  till'  fair.     It  in  broad,  liracliyccplmlic,  ilu'  transv.rsf  diami'tcr 
approaching  that  of  the  antero-postorior.     It  \h  llattoncd  in  tlie  fon-head 
and  fiviiiicnliy  dcpivHscii  and  Hlojiing  i)ackward.      The  two  halvcw  <.l 
tlic  licail  arc  odcn   aHynini.irical.     The  MiilurcM  arc  often  occupied   liv 
Wormian  lioncs.     'riic  neck   is  large  and  t^liort,  and  tlu>  tliyn.id  glariil 
may  lie  .iilarged  or  may  he  completely  ahwent.     The  thorax   i.n  iimimIK 
detormed  in  association    with    lateral  or  antcro-posterior    curvature  .!| 
the  spine.     The  ahdonicii  i.s  prominent  and    full.     The  limlis  are  ex 
tiemely  sihort,  .sometimes  enujciated,  ocea.sionally  deformed  liy  rickets. 
The  muscles  are  fee!)le,  the  hands  and   feel   are   large,  the  lingers  thirk 
and    liroad,  and    the    nails  olteii  coar.se  and    large,  and   may  he  rudi- 
mentary. 

There  are  varying   grade.s  of  cretinism,  and  ju«t    as   we    recogni/c 
complete  idiocy,  imhecility,  and   feehle-mindcdness,  so  there  have  heen 
descrihed  three  degrees  of  this  alleetion  :  cretins,  which  present  in  a  iM..st 
advanced  degree  the  jdiysieal  characteristics  ahove  mentioned,  ami  .ir, 
in  addition  deaf-mutes  with  tlie  vegetative  functions  alone  active;  semi- 

cretins,  with  mental  dulne.ss,  harsh  guttural  voice,  expressionless  ( i|. 

tenance,  and  the  physical  condition  similar  to  hut  less  pronounced  than 
that  of  the  true  cretin;  and  lastly,  the  cretinoid  condition  in  wlii.h 
there  is  .some  degree  of  enteeblemeiit  of  the  intelligence,  speech  >oiii,- 

what  impaired,  and  the  physiognomy  and  physical  i formation  i-  that 

of  the  cretin. 

The  recognition  of  the  condition  of  cretinism,  though  ea.sy  in  advanced 
and  typical   ea.-es,  is  often,  I   !ind,  not  clearly  made:  I  judge  this  from 
the  numlier  of  descriptive  cases  sent  to  me  as  instances  oif  this  eomiitioii, 
hut  which   in  reality  have  heen  cases  of  various  forms  of  idiocy,     Tlie 
imjiortant   criteria   are  the   |)hysiognomy,  the    slia|)e  of   the    head,  ilic 
stunted  growth,  and  the  condition  of  the  connective  li.ssues.     The  menial 
deticieiicy  is  less  characteristic,  presenting  nothing  not  seen  in  instances 
of  ordinary  idiocy.     The  condition  of  the  thyroid  is  uncertain.     Tlure 
are  cretins  with  and  cretins  without  goitre,  while  in  others  ih,.  u-lamj 
seems  entirely  alwent.     The  most  .satisfactory  diagnostic  leature  i-  ihe 
condition    of   the  skin  and  connective  tissues,   whidi,  as   Ilorslev  .-iii;- 
gests  in  the  following  words,  shiaild  form  really  the  basis  of  the  chi^-ili- 
eation.     "  Hy  excluding  all  cases  in  which  the  appearance  of  idimv  i.^ 
not  accomimnied  by  any  noteworthy  changes  in  the  skin  or  conncciivc 
ti.ssues  we  obtain  a  considerable  delimitation  of  the  condition  wliirh  ue 
ought  to  call   cretinism,  for  by  adopting  such  a  plan  of  diticreniiniinii 
we  necessarily  leave  out  all  eases  due  to  direct  injurv  or  .iisease  ,.r  ihe 


i:;t;i;;;::;:::;:;;::'i!;;:;;;';;^  .<....... ,i.„...„_, 

i.li.K.v   (ollowi...    .nr..   I  .  '"■•"'"'«^-..-l.  a,  ,.on...ni,al   i,|i....v. 

-■'-p-'-' '.y  wan,  ,,r  .2:1: ' ;,  i:"''''''"^  ^ 

;:.'n..ral  Him,,...  i,,     |,„  ;,„„.'  ,'    '    '   """  '"  ""  ''"'"•f  '>''  -•'•lainlv  „,. 
l->w.,  ,.|a>.i,i;.a,i„n  '  "'"-""'  "^•''  "'^  '■'"•"'■^•-■^  "-  Imsi,:,,,' „,.. 

-.te  relationof  th    ...     I      .;   '  ' .''"'"•^-     """"""'-.  an.l  ,1...  in.j. 

'ikely  ,o  ,nn.  .etinou.  HUI,,  J.  :i?  1^:^^^^^^^  'e 

'■■■"•'■"'■^"1   "l-n   •■..n.liiions  of   ,1„.  ,,,,.,,;.        ,  ""^'"'"l"'""'"'"'''  "f 

"'y-'i'l  i«  >'s,nillv  absent,  an.l  in  mII  .  ',■  I    i   r        .     '  ''""'*""''  ''"■''■■^  "'« 

^v.nMw..u.,ea..en...,.n.a.S;;;;rj:;::;;j 

-  ='I..-.  ,o  I.  at  all  .in.'  n  ;^ep      ::V'""  ""'^  "^'^''"■-'"  ''<- 
"'  -'y  Hite  it  i,s  Htat.l  l.v  IJart  ,n  t  i  J  '""    '  '"  ""  "''''  •■'-'""  ' 

"-  l'"i'e.l  Stat...     JJnnvn     ,e  ;"  "  '^  '""  '•"'•^■'>-  -'  -•"'  i» 

^^l'"l.  state  r  have  l.e.-n  al.le  to  levr      n.'.         "'   '^  "«*^"^''"««t'«  («>r 
P'it.v..it  in  .state.I  that  th.re  a       u'r  "     "'"  ""•'"''•^"'■^^  "^ 

-'-""' I-I-Ia.i rahont     L:^inriV:i     T'l''''^^""'' 

somewhat  fVe.,u..nt  ca.seH  of  oretini  n    „  7  '""  "'•"^"  ''^''^''^'^ 

-..•Cape  M^nUoeino.  in  C.^  ':::;;; '\;''"'''  "'  ^";"'-  '-"« 

;^<'  -aonntainons   parts  of  Souther  '.        J  I  "''':;:r'^'^  ^' -''-•' '^  '" 
Hn.h  pass  current  i„  varions  works      tZn  «t"^^'"H'"t.  of 

-i....  on  the  su.>jeet.  in  the  ^  V   '  v//'  7^  7'  '""  "'  'T    '"^"^ 
«ays:   "In    North  An.erica  cretinit  o/         '''•^■'■"•^•- 'l'   ^•/''W../,' 

veunont,  m  Jiassachuaetts,  and  in 

»=:""""■""" ' '"""- "■ H, .,.,..,,..„ ,, , 

■•4".  "(•r..tinlsme,"byliniliftngi.r, 


Vi.l. 


"  .nn."(Tt;t( 


IIISIII.' 


vri'i.vliiiljtT. 


r 


6 

Calitoniia.-'      AVhen  wo   turn    to  the  ..ri-inal  somres  f„r  these  state- 
ments, nearly  all  „f    which  antedate   l.SK),  we  fin.I,  tor  example,  the 
authority  for  tlie  occurrence  of  the  affection  in  A[as.sachiisetts  the.reneral 
statement  of  Kneelan.I,'  that  there  are  twelve  hundred  idiots  an.reretins 
m  a  i)o).u]ati,.n,,l'„i,e  million.     I  can  find  no  detailed  observation  in  this 
article,  and  the  term  "cretin  "  was  probahly  used  in  a  loose  wav  t„  indi- 
cate some  variety  of  imbecility.    Ho  far  as  I  can  ascertain,  thestatemenN 
as  to  the  existence  of  the  disease  in  Vermont  and  New  Hampshire  re-i 
on  a  paragraph  in  Buckminster  i'.rown's  article  on  cretins  i„  Switzer- 
land :-  "Simpletons  or  idiots  are  to  he  met  with  in  the  valleys  of  Ver- 
mont, Xew  Hampshire,  or  Sctland."    There  is  no  reference  to  cretinisn, 
in  Dorr's' account  of  the  prevalence  of  goitre  in  the  vallcvsof  the  ( ircen 
Mountains.     Trask,  of  Windsor,  Vermont,  speaking  of  [he  pix-valence 
of  goitre  among  the  early  settlers  in  the  valley,  says:' "  In  most  countries 
goitre  IS  connected  with  a  species  of  mental  imhecilitv  called  cretinis,,,  ■ 
but^in  the  United  States,  thanks  to  God,  it  is  a  mere  corp(,real  affecti(,n.-' 
Traslow's  account  of  the  occurrence  of  cretins  in  California  I  have 
not  seen,  but  I  have  letters  from  several  correspondents  in  thnt  s'nt,. 
who  know  nothing  „f  its  existence  at  present,  while  in  the  Stat';  Insii,,, 
Asylum,  at  Stockton,  Dr.  Hoisholt  tells  me,  there  are  only  two  cases.' 

Barton,*  whose  essay  on  goitre,  pui)lished  in  the  year  l.SOO,  is  one  oC 
the  few  systematic  attempts  to  study  the  distribution  of  this  di.sease  in 
America,  states:  "  I  have  heard  of  some  cases  of  cretinism  among  (1,,. 
Indians  inhabiting  the  neighborhood  of  San.lusky.  But  such  cases  are 
undoui)tedly  very  rare  in  North  America.  This  circumstance,  as  I  have 
remarked,  is  well  calculated  to  show  that  goitre  and  iodiotism  are  not 
necessarily  connected  with  each  other." 

Here  and  there  one  meets  with  the  assertion  that  cretinism  occurs  in 
Lower  Canada  among  the  French,  but  I  have  not  been  able  to  trace  thr 
allusion  to  its  source  or  to  verity  the  fact  of  its  existence.  Some  vears 
ago  I  looked  through  two  of  the  large  institutions  fbr  children  in  .Mont 
real,  and  the  Limgue  Pointe  Asylum,  without  finding  any,  and  luo 
cases  supposed  to  be  cretins,  at  Cacouna,  proved  to  be  remarkuhle 
rhachitic  dwarfs. 

The  more  recent  literature  descriptive  of  cases  is  ms.  very  sciuitv 
Jacobi,  in  the  Jlu.jjilal  (lazdtt;  x\.  V.,  187!»,  vol.  v.,  ics..'  died"  hriHlya 
case,  the  first  on  record  in  this  country— a  child  of  e.^nt  years.  .I„li!i- 
son's  paper,  in  the  Detroit  Review  of  Medicine,  January,  \i<l^,  contains 
no  statements  about  cretinism  in  America. 


'    AMHIUCA.V  ,r(U-]lNAI.   Ml-  Till.-.    .MkHKAI.   ScIKNc  e>,  .\|inl,   K)\ 

■  Iliiil.,  is|-,  ix.  ]i.  ill. 

■'  Now  Yiirk  .Mo(|ioMl  Ik'iwsiUiry,  x. 

■•  HfM.i.  Sn.itI,  H„rloM,  ITofosoruf  Matoria  .\K.,li,.,i „•  l-iiivL-rsllv  oC  IViin^vlvaiir.     ■■  \ 

"''"'""■  '■ '■"'"•«  I'l^'  "oil"'  ii>  il  ITovails  i„  DiiUTiMit  I'Mits  of  .\„hIi  Amoiioi  "    !■■,  •.■| 

Plilliiilflpliiii,  ]S(i(i,  ■        ' 


""common  among  the  ohUdron  "  in  fl..  .     '""'"  "'"«  ""^  ^•'^''v 

owing  to  the  inH.tx  of  inn    .    '    /"-      /'"'"f  "* ''''^'"^^•^  "^^'^^^eu-  York 
■'-  to  the  foets  of  its  preSr  ""  ''*"'""•'  '''•^^'  =-  --ilablJ 

I'ave  led  in  Knrope  to  .taten    „  1  a   V  h         "'  ''''''^-'^"-^^  -hieh 
-ien.-e  fonn,  have  heon  has      i     ...  ^    ''''  'I'-^'^'^'^-  "^  ir   iu.e  in 
-"'  ^^t'"'i-  upon,  goitre,  n,a.le  f        .'    f  7"'  "."•■•'""'«'  -''--e'-e-  to, 
-"^-T-     ^o  far  ,;  I  cm  lea  n     l.e    i    ^    T"  '"  ""  "^'•'^'  '""'^  "^■^'- 
<-1-'i-lly  in  this  eonntrv.     U  mlJ t       '"V"'  ""'  ''""  ""^  -^'^ 
^••-t  goitre  whieh  I  have'gl.meZ  nv  f'    '"'/"  ""'^  ^•"■^'*'"  ^'''^^ 
refer  to  this  n^ahuiy  only  s.rfh,.  •  ,  i  '  ^  ^,     T'T'  """  "'''^'''  ''-^■^'^■e'', 
orotini.n.  in  a  locaiitv.     Hirs    .     i         '        '  ''^''''^  ^"  '^''  '^'^^^euve  o 
P--'enee;    and,  as' he  re^lu^J^'^^  l''^^''''^^ -''"-^7  a.  to  its 
opcurrenee  of  goitre  in  North  Am'eriea    .  ,1  "'*'"'':'"^';'"  «"   ^'e  endemic 
'-■'y  yeans  of  this  centurv  a„d1   v        t        ''^"  '"''  '"^^  '"^^  1"-^  to  the 
"'-"'y  -ferred  to.  and  the  a  t    I  s  ^f  ^^Jl^'^'^^^;"     '^--f-'^  -uen.oir 
"""  the  n.ost  authentic  inf.rnvuion    ,   V         ""     ""^'  '''  '^'^""«^ '  ^<'»- 
suhse.juent  writers  have  .Irawn'  fl,,,!..    •    "     '  '."■''^'*'^"<^e.  tVom  which 
■■"'"  'J^^^ails  which  are  avaih.b  e   „      i'.'l      ''""?""'     ^^^'"^'"'"^  ^^''^^^'-'''g 
goitre  has  been  described     s  p    v     in    "  ""■^' .'' ""^^-  '"  '^'^'^"^  ^ha! 
along  the   Detroit  Kive,  Z'I^ZT'T^''  ""'''''''  ^-'-'■'-'^ 
John  and  Montreal;  in    he  v a         ',     V  '"   '''''''   '''^'"■^-»  ^^■ 

•■"  fl'''  "-fal  parts  of  New  V  r  '        ,  ^  T""'  '"'  ^"^^  """'I-hire; 

'I'e  Caroiinas;  an<I  in  Aiaban.,      F   T         ^^^^P'land,  Virginia,  and 
"e  l>ave  no  recent  observations     '  J  h  "  •""•'"'■''■'  "*'  *''^'^^'  '•"■«'ities 

<ii"i.-'  in  the  towns  of  Xe,v  Fn„h,n,l   ,     \"''''^\^"  '"  '^  "u.nber  of  phvsi- 
"«--l.  and  so  tar  hav^  L  ?  T  ^       '^^  ^^'-"  - -T 'mnch 

Ciark,  writing  tVom  Windsor,  V:' .  ::7;i;:7-      '"'"^  '^^^   '^• 

""'^'"•'y  "•'•iters,  says  tiiat  in  the  nast  fiffl  ?      '  '"en.,oned  by 

I-".'  very  prevalent;    and    D      Ce^  rT'   " '''"  "'^  ''^'-'' •'^' 'ts 
*''-"■'■•  ^'-™ont  (a  town  one  In  It  ^f  t  1  T  ^  ,  •  "'"'^'  '"•^^"■-'   ^^ 


■^■■'■'"^•^'^'"■l' .ln,.,sx„v,isii2. 


'  iniemniioiml  Cliiiios,  v,,l.  ii    ,,,.,,,,. 
'  ■^''"-'  l'l"la,lolplii„  Journal  of  th,.  Vn,v     , 
'"   ^""^  Moiliral  Hopository,  is,),;. 


ly 


/ 


8 

.special    extent.-'      Dr.    R.    J.    Preston,    of  the   Soutlnvestern    Lunmie 
Asyliim,  Marion,  Virginia,  lia..  very  kindly  made  in(,uiries  as  to  ti.e 
existence  of  tlie  disease  in  some  of  the  southwestern  counties  ..f  that  State 
in  wiiieh,  as  stated  in  Gibson's  .S'»rr/m/,  the  disease  formerly  prevailed,' 
and  here,  too,  it  seems  to  have  almost  disapi)eared.     Dr.  W.  Taylor,  of' 
Talla.lega,  Alabama,  who  is  the  authority  quoted  by  Hirsch  in  support 
of  the  statement  that  there  is  a  "good  deal    of  it"  in    the    northern 
counties  of  that  State,  writes  (1,S!»;!)  :  "  Since  that  time  [lSo4]  my  views 
on  the  subject  have  been  greatly  modified.     With  a  mu.d,  larger  popu- 
lation there  are  now  really  fewer  cases  of  goitre  to  be  found  in  Tallade<ra 
and  adjacent  counties  than  in  the  earlier  period  of  their  history.    .    .    " 
The  fact  remains  that  there  has  been  a  great  decrease  in  the  pi'evalenCJ 
of  goitre  during  the  jtast  thirty  years,  and  the  percentage  of  cases  will 
not  surpass  the  average  in  other  States  and  communities." 

In  the  Trovince  of  (Quebec  cases  of  goitre  are  by  no  means  rare,  and  in 
Montreal  the  disease  is  certainly  more  frequent  in  hosj)ital  practice  than 
in  Philadelphia  or  ]Jaltimore.  I  have  no  information  of  any  localitie> 
in  which  it  could  be  said  to  be  endemic,  attacking  a  very  large  number 
of  persons. 

In  the  neighboring  Province  of  Ontario,  in  the  limestone  re-ions  at 
the  end  of  Lake  Ontario,  the  disease  is  very  prevalent.  In  response 
to  my  iixpiiry  about  cretins.  Dr.  V.  K.  Clark,  of  the  Kingston  Asylum 
mentions  the  extraordinary  prevalence  of  the  disease.  Thus  in  an 
asylum  poi)uIation  of  about  600  there  are  288  eases  of  goitre.  He 
writes : 

"The  goitres  are  generally  developed  when  the  patients  are  admitted 
to  the  asylum,  and  it  is  rarely  indeed  that  we  see  recent  cases  unle.-s 
among   the   employes.      After   studying  the  subject  carefully  I   have 
come  to  the  conclusion    that   Eastern  Ontario  is  a  distinctly  g(,itn,u.s 
district,  and  I  do  not  believe  that  outside  j)ractitioners  have"given  the 
matter  any  attention.     It  is  difficult  to  get  accurate  statistics  even  from 
asylums,  and  for  this  reason  I  have  never  published  the  returns  smt  in 
from  nearly  every  hospital  fur  the  insane  in  America.    A  .superintendent 
would  answer  my  circular  and  state  that  his  institution   was  withmit 
goitrous  i)atieiits.     I  would  go  to  his  institution  myself  and  probably 
find  twenty  or  thirty  goitres.     The  inference  was  plain,  an.l  when  in.ti- 
tutiuus  side  by  side  gave  returns  showing  marked  differences  the  infir- 
ence  was  plainer  still. 

"  Outside  practitioners  about  Kingston  have  written  nothing  of  interest 
in  connection  with  the  subject,  but  I  find  goitre  prevalent  even  anion.' 
the  lower  animals  ;  most  of  the  curs  about  the  asylum  have  goitres,  s.mi'e 
of  them  so  large  that  anyone  can  notice  them.  The  tendency  ti.  ihis 
disease  seems  to  run  in  certain  strains,  and  the  youiitr  of  some  fan.ili,-  uf 
dogs  and  horses  are  invariably  goitrous.     In  two  cases  of  human  beiii-s 


9 
troitres  l.ave  pn.ved  fatal  throu-h  pressure       \t  .„    r       r 

-   believe   that   mental   <ii.oas:  .  i^uX  ti;  ^ " ''"w   ""  '"''T' 
presence  of  .r„it,-e  in  so  innnv    e  7  ^"^t'"-  'Jetennininir  the 

f; ««■" u:ir';ii:is;^ :  ;".,zr:'rT" ' 

Asyhiiii.    Tlie  mitres   ni.t  witl,  i„  ,i  ""  '^"i«»t™i 

thcreseems  to  bea  hazvidfi  fl.Mf    .n     i  _  '  i- ^'"'innt.      W  ith  some 

'■t  "T  f"', '-'^^'"^  '^""  •'=''  '"™.it';r,  '"i '• 

Miithing  to  show  that  siifl,  ;.  fi,„  ,     ,    '"  ^'"*' '"'Strict.     Ihure  is 

.ere  are  „„  cases  .,f  a«i„l„„  i„  ,|,e  Ki,,,,,,,,;,  AsvI,„„ 

e,.le,„io,  i.  is  tow  ;;^.J;', .;;:::'■ "'"'  '  """■'■'  "■  "'"*  K*-  -» <™,eHy 

Eiidernie  cretinism  does  not  exiof   uo  ,., , 
or  Cana.ia,  nor  is  it  at  all  p  X.M     '.         7  ''''  '"  '^''   ^^"'f'"'  '^''^tes 
ever  existed.     My  in  ut  c        'v  T  "'"  '-"""  '^'^'•"'  ^'''-^^  '"^  ^as 

to  New  Mexieo,^:r^ri  r^t::dir:';;::tr  '^^'■"-  :"'•• '''-' 

occur.  "  ""^"  fe""tre  and  cretinism 

»"  -  iii»,i  o„„„.„-es,  a^r    ,  ,i  i' :;  H  :;,;7"'' '-« ";' "--  i» 

cmii.tlT  relate  iKmicnl'irlv  „., I  '"""    ""«'«  i"  Hk 

'"  -aritv  ,.,.y  ria  I ;  i^    .r;:':",?  f  "*  ""■'"  ■"■  '"=  """""■>•• 

.»..lai„,  .here  l,„ve  l^te    1        I  ''"'  "''  '"  ''""• '"  '"  »»  '  ««" 

"f  .m™  cases  at  the  ,l„l„„  ,1  1^™  ft,!  ""     t™","  "!  ''"I"''  •'""-■'-'*«' 
i«le.«l  to  the  ,„e„,bers    ,f  ,  !  A  '      "'"""''"  "  "-""I'l  ''«  "' 

,c„ssi,.  :  .™,e™"  ■:,""'  ';""""'"'■"■  ■■"  """""- 

<";.ll  .!»  a3yl,„„  s„,,eri,„e„.le„.s  i,    tlfe  U  t  j  L.^      Tr.  "T 

.!«  »;a.re  prevaiW  en.len.ic.lly.     A,„„„g    ,,  ,, '  „'.'""'  ""'« 

were  (  escr  nt  ons  of  i»nni.  ,.,..       i'  •  i-    •     ^  'i-|)iics  wliicli  1  received 

'»  "«ias  ^1  iV    ?  "  ,     ,"'°  °''''''""  "'""''  «™  "-'feMlv 

the.™    ei      ■      1  :  '^^         '""'■'';"  --  '  "a™  «(erre,l  t,' 

•ill  !■'■  8iv.a      I     ,1  it  "    f         '"■'"'*"■  ""  ''"""'I"'""  "f  "hid. 
««..™«.a.  ,„  te  :,  r;'"""""  '"l»-i«o.„len,s  there  were 


10 

or  four  years  of  life.  I  have  at  present  two  cases  uikUt  treatment,  Inn, 
botli  for  such  a  short  time  that  it  is  impossisK'  lo  say  as  to  the  chanf,'i's 
ill  the  noiulition. 


r 


t 


■n 


ill 
it 


w 


Cask  [.— ^[.,  aged  (now)  two  years  aiid  three  months,  was  l)roufi;ht  to  luc 
first  i'r  )ni  the  Eastern  Sliore  of  Maryhmd,  .laiuiiiry  '0,  1S02.  Tlu'  piircMii- 
(tirst  cousins)  are  healthy  and  stronir.  No  hereditary  aihnents  on  cither  side  ; 
no  members  of  the  family  Inive  had  jroitre.  The  patient  was  the  wecond  chili]  : 
the  labor  was  easy,  and  she  throve  well.  Xotliing  special  was  noticed  aboni 
the  child  until  tlie  end  of  the  first  year,  when  it  was  susjiected  sonietiiiii>; 
miglit  be  wronjr.  as  she  iiad  not  cut  lier  teeth,  and  did  not  attempt  to  walk  di 
to  talk,  'fhrongiiout  her  second  year  she  };rew  fairly  well,  but  had  several 
attacks  of  sliirht  fever,  and  did  not  develop  as  other  children,  making  no 
attempts  to  crawl  or  to  walk,  and  seemed  unnaturally  (piiet  and  dull.  Shr 
did  not  cut  the  incisor  teetli  until  she  was  nenrly  two  years  old.  Within  the 
past  si.K  months  she  has  changed  remarkably  in  color,  has  become  very  pale 
and  '.vasy,  and  the  face  and  limbs  seem  iiully  and  swollen.  She  lias  lakcn 
milk  well,  and  has  developed  a  little  mentally;  smiles,  and  attempts  ii, 
repeat  her  own  name  when  it  is  said,  and  has  learned  to  say  ''  mamma"  .iml 
"papa." 

/'resent  condition .  Under-sized  child  for  her  age.  Aspect  is  very  strikiiiir; 
color  jiale  ;  face,  very  broad  across;  the  mouth  is  open;  tongue  jirotrudes, 
and  is  evidently  enlarged  ;  the  lips  arc  full  and  heavy  ;  the  cheeks  very  larire, 
almost  pendulous;  the  hair  is  long  and  straight;  the  eyes  are  blue;  tlie 
sclerotics  very  pale;  the  eyelids  glossy  and  infiltrated.  The  forc'hci'.d  is 
large,  not  l)adly  shaped;  the  head  well  formed,  rather  prominent  behiml; 
the  anterior  fontanelle  is  not  cpiite  closed.  She  looks  good-tempered,  hut 
takes  very  little  notice,  and  smiles  in  a  feeble  way.  The  facial  aspect  is  that 
of  a  cretinoid  idiot. 

The  muscles  of  the  arms  are  feebly  developed ;  the  siiln'utnneniis 
tissues  are  much  infiltrated  ;  the  hands  are  swollen  and  glossy — not  teiiso, 
and  look  oedematous,  but  the  infiltration  is  firm,  and  only  yields  nn  |iiii- 
longed  ]M'essure.  The  legs  look  large  ;  the  thighs  present  several  folds;  the 
skin  looks  glossy,  and  the  subcutaneous  ti.ssues  are  much  infiltrated,  'i'lie 
skin  over  the  dorsal  portion  of  the  feet  is  very  glossy  and  tense,  and  <in  rinn 
]iressure  pits  with  distinctness.  The  abdomen  is  distended  and  the  superlicial 
veins  prominent.  I'alpatiim  is  negative;  the  edge  of  the  liver  is  palpalile 
about  six  em.  below  the  costal  margin.  The  edge  of  the  spleeii  is  not  palpa- 
ble, nor  does  the  organ  appear  to  be  enlarged.  The  thorax  is  well  formeil; 
no  trace  of  rickety  enlargement  of  the  ends  of  the  ribs;  no  evidences  nf 
ricket--  in  the  long  bones.  The  apex-beat  of  the  heart  is  just  within  tin'  iiip- 
jde  line.  There  is  a  systolic  niuriuur  with  the  first  sound,  which  is  loud  and 
intense  at  the  pulmonary  cartilage  ;  the  breath  sounds  are  clear.  There  is  no 
enhirgcment  of  the  superficial  lym|)hatic  glands;  the  thyroiil  gland  is  not 
enlarged  ;  tiie  cricoid  cartilage  can  be  well  felt,  as  can  also  the  entire  trarhea 
as  low  as  the  sternum,  and  it  can  be  taken  between  the  two  lingers  i|niic 
plainly.  Dr.  llalsted  thought  he  could  feel  the  thyroid  benc.tlh  the  siciiin- 
mastold  muscle.     The  percussion  note  on  the  first  bone  of  the  sterniuii  is 


I  m 


riear. 


'Jl 


le  cxiuiiiii; 


11 
of  tlie  l)l()i)(|  showeil 


Tl..  condition  wa    di« L^     ,    ":     ''V       '''-r'-n-sHe. 

ordered  the  syrup  of  the  i.Hli,!;, ,;;;':,!  ""  "'■^'  ""•^■''  '""'-  I--  «'>e  was 

-I/^"W,  1,  l.sii;;.    Patient  hro,if:ht  a-ain  to  d.,v      l„,i 
which  have  clapped  since  I  sa^the  cl      1    h       ;    i  "  T  "'"'  '""  '"""'1'^ 

is  now  three-and-a-hair  vears  ,1  •  ''l""'^'  ren.arkably.     She 

intelligent,  takes  n.o,v  no,   !    .^^  u.et.i  f"      ''  ''  ''"■    ""  '""^^  """•" 
She  tries  „.  sav  a  (cu-  won  Is  C  1  ^-^l"-''^*"""  '^^  <l-i.ledly  brighter. 

The  n.ost  strikin.  cl.."  s  t/  '     f  '"^'""  '"  "•"'^-  "•'"'  '^  '!"'«  assistance. 

ii".'-  also  look  lull,  and  ^  ^     "";  r;^'"'^^"";'^  -"  ^''-'--     The 

l'^"Hl.s  and  feet.     The  ton^afe  ,1         .  ','"  "  '"  ''"'''  ^'l-sy  over  the 

tlH.ugh  when  the  fac  n    e,t"i    i    /"'"'""'r  •""  "^'^'■'  ''''"'  ""^  '"-tl.. 

The  face  looks  broad f.       ;'      L''  "  '"'>!"^" ">'--'   P-tmding  sli.htlv. 

ifead  is  .-,1,.-.  ,.„..  i„  circl  ;  e  u.  M  "'"  '""' '"''"'  "'■^'  ^^"'  -"'■^'""id  : 
and  sh,„.,,  and  prese,  "  •"  ll'  "'"'"'"r;  "'  '  "'"■  '^'''"  "^^^^  is  thick 
'^  "-  palpable.' and  Z^JZ  Zld"  '  '"'  '^  ''"  '"^^"'^  *^'-'' 
will,  .he  greatest  disti,,ctness  1  /  ,  '"""  ^'"^  ^''"^■''^■'^  *^''"  ^^  ^t 
sternun,.  '""'  ^'^"^'""'  '^'•'"■*^^"  "'«  ""gers  down  to  the- 

..j:;:i'=:i^e;::;;;::.:;:;;;;- ';:--^'«  eretm..  treated  with  the 

taking  the  glycerin  extract  oHir^e^-'u^r'''''''  '"  ^""''  "'^^  •'^^" 
-  ''•"•••'  ='  'l"arter  of  a  gland  in  the  n  '  ^  t  ^^  17'  ''Tr'''' 
as  ye,  notiml  after  nearly  a  month's  trealnle.u  '^  '''""^''  ^'^ 

i.os;i;aM:yh:;^:;;^;;;':;^::;;7;:;:;;^!;-.^^^^^^^^^^^ 

are   not   blood    relation   ;       ,     i^'en  '''•'''"''"'"  ^'''"^' '■  '"^''-'^^ 

troMhles.  Patient  is  the  second  hi  dl''''"''''^^  ""  '''''"''  '"'  '"^"'<'»1 
I'-lthy  when  born  ;  fat  and        I       l;,'  '""•^'  T  "'"  '-'—"al ;  she  was 

thee„dofthisti„,etha,i     V         ;,S'h^';''"  ■  r^T"""'''^^''^""''"^ 
She  did  not  seem  to  grow  a„        Zt^^V^Z  '""''T""  I"  ''«-'""-"*■ 
food  well,  and  was  in  other  respect.s  o    i        .u      ''T'  ^'"""'^  ^''^  ^-l^'  '-^ 
thought  that  she  was  eoinpletelv  idiot!      ,!.  '  ,     '""  "'""'"^  ■""'"'•'^  ''  ^^^^ 

'0  1-..W  what  was  said  to  her  si  i,','  u''' "''"'  '""'^'  ""^'''^^  '""1  •^^^™«1 
the  lap.  and  the  tonguw  :„:.;':'  7\  '"i  '^"'  '"'  '"■'''  ^"  '^^  '-'^  '" 
-.  h.gin  to  cut  her  Teeth     „  i     t      frd       r     1  '''""'  ''''  '""""'•     '^''^  '''-' 

twelfth  year,  The  anterior  Con ta  e  d  ,  ""  ""!'  ^'" ""  '^"""''• 
year.    She  did  not  begin   to  walktnt  '  .it!    '"^  T''  '^'^'"" 

leanicd  to  read  or  to  write.  i«eirtii  3  ear.     .She  has  never 

l're»'iit  coitditioii.     Her  heiiMit  iu  n,..„„  *•    .    • 
the  feet  are  turned  out  t  Iti:  a       t  .  r  '     """  '''"''"'■    '''"'  '"'''''''  ^-^i'v  ^ 
pit.  wi,h  ,he  hands  spr  a      '  T  1     '  ^•""''       '  "^^ 

The  expression  is  pleas  nt     she  s    il      1      7    ^''  characteristics  of  a  cretin, 
has  a  cluldish.soL^h      :i    ;  :     '"'''■'«''^''^'  '•""'  ''-'^■■'' ^-«^1  "atured.  but 


V*., 


ly  e.Kpressioii. 


"e  sits  quietly,  as  a  rule,  with 


II     ^ 


i 


12 

her  iiioiith  slmt,  but  soiiictiiiips  the  toiiiiiic  protriKlcs  between  tbe  li|is.  Tlir 
f'liee  is  liroad,  luid  all  the  leatures  thick  iiiid  eoarse.  The  nose  is  nimny^i. 
the  nasal  (irifiees  very  apparent,  and  the  ahe  thick,  and  measure  across  the 
margins  fully  5  mm.  in  thickness.  The  lijis  arc  thick  and  lull;  the  clicek- 
])niminent,  larjie,  and  broad.  In  tjie  ujiper  jaw  the  lateral  incisors  are  absent : 
the  central  inci.sors  are  of  fair  size,  the  enamel  much  eroded  ;  the  canines  arc 
small,  also  witii  defective  enamel.  The  premolars  and  molars  are  small  and 
much  decayed.  In  the  lower  jaw  the  teeth  are  all  present,  but  they  arc 
irrcjinlar  and  show  the  same  character  of  defect.  The  root  id'  the  mouth  is 
much  vaulted,  the  palate  is  not  defective.  The  forehead  is  full,  a  little  proM) 
inent  in  front;  the  head  is  long;  the  occijiut  jirojects,  and  it  is  broiid 
immediately  behind  the  parietal  eminences.  The  occipital  iirchcs  are  iihk  h 
developed,  and  there  are  thick  ridt'c-like  p.ojections  at  llie  line  of  the  s(|uaiii.i- 
parictal  sutures.  The  circumfen  nee  of  the  head  is  51.^  cm.  ;  from  the  tip  .if 
one  ear  to  the  tip  of  the  other,  27  cm.;  from  the  occipital  protiiberamc  to  the 
glabella,  88  em.     The  ears  are  well  formed. 

The  neck  is  Hii  cm.  in  eircumference.  The  thyroid  gland  is  diatinetly  en- 
larged ;  the  left  lobe  more  than  the  right.  The  hands  and  arms  are  well 
Ibrmed  ;  there  is  no  enlargement  of  the  epiphyses,  ^he  uses  her  fingers  will. 
and  can  feed  herself  and  jdck  up  small  objects,  but  the  movements  are  some- 
what clumsy,  ami  she  is  unable  to  dress  or  undress  herself  The  legs  are  linn 
and  strong;  not  bowed.  The  gait  i.s  as  above  mentioned;  she  falls  easily, 
and,  as  her  mother  e.xjjressed  it,  has  no  elasticity.  8he  is  flat-footed.  The 
kiu-e-jerk  seems  slightly  increased.  The  body  looks  squat  and  full;  the 
thorax  is  capacious;  the  back  shows  a  moderate  antero-posterior  curvati:rc. 
The  abdomen  is  large.  Examination  of  the  thoracic  and  abdominal  organs 
negative. 

She  is  well  nourished,  and  the  subcutaneous  ti.saut^  are  firm  but  do  not 
pit,  and  there  is  no  appearance  like  that  of  myxedema;  it  is  only  in  the 
thickness  of  the  features  that  the  condition  is  suggested. 

>She  talks  a  great  deal;  the  voice  is  high-pitched,  very  difficult  to  under 
stand.  Some  words  she  speaks  clearly,  and  she  talks  and  behaves  very  much 
as  a  child  of  two  or  three  years.  She  is  easily  amused  ;  showed  with  gnat 
pleasure  and  childish  joy  a  little  new  ring,  and  is  very  fond  of  |>retty  things. 
She  has  a  very  good  musical  ear;  can  sing  several  little  songs.  She  is  vcrv 
good-hearted  ami  generous,  and  always  very  anxious,  if  she  has  anything 
nice,  that  the  servants,  who  are  devoted  to  her,  should  share  it.  She  is,  how- 
ever, self-willed,  and  does  not  like  to  be  thwarted.  She  began  to  menstriiMte 
eighteen  niontlis  ago. 

Case  III.  (Dr.  Hooker.)— Minnie  K.,  white,  aged  three  and  one-half  yc:ir-. 
came  to  Johns  Hopkins  Hospital  Dispensary  November  2.5,  18i)L'.  She  w.is 
born  In  Lebanon,  Pa  ,  and  lived  there  until  one  year  ago,  when  she  was  moved 
to  Steelton,  Jld.  Horn  in  natural  labor;  mother  had  only  three  hard 
pains;  was  a  fat,  healthy  child  up  to  second  summer;  when  one  year  nid, 
had  sumner  diarrlujca,  about  sixteen  stools  daily  tor  a  month;  after  tliiii  the 
bowels  became  regular,  and  the  child  improved  for  a  short  while,  then  Ncgaa 
to  waste  again  without  anything  to  account  for  it.  She  had  no  cough,  no 
fever.  There  ap[iears  to  have  been  no  growth  aiul  no  improvement  -i'.tce 
the  attack  of  diarrhcea  at  one  year  of  age,  excepting  the  slight  improvdneiit 


13 

-  brought  t..  t..:  di:  ::^Lt;:;;::r.'t;:'^''"-^'"«''-  '^"^  ^ • 

-arse;  lo-.gue  Im    d  •  i    t'l   ,.1         - '  '""  '"-'"''   '''^'''^''^'^''^ '  "l^   '''ick  h.uI 

nearly  black.  (The  two  lower  incisor,  w^e  '  u  i,  '  .  "  ,'  '"''"'  ""' 
a.'e,  and  Just  before  the  diarrhea  con.me ".hI  Th  S  '  '  n"'"  ^""'  "'" 
the  time  of  slight  improvement  in  tl  "  , '      ^ '''   '"Howmg  October  was 

tins  tin,e  the  Uvo  u,.,  c^r  nc  I  we^T"  ""':"'""  '"  '"''  '^''"'^'  -"'  »»* 
t-tl'.)  The  nose  is  lat  and  3  ■  '  7T  '''^"  ^''«  ''««  ^ad  no  other 
.In.k,  coarse,  chestnut-  .wtd^r  '  si^uir  '"'  I'"'!  ^'"  ''""'  ^■"'--''  "-V 
-es  very  sn.all.     There  is  s  ,„  '  e   l',,  .'"'"  .'"  ^""'  '^''' '  ''■^^"^^  •>''  "'« 

tio'-id gland, btttitr;: :  J  j::;';: ;: t''^t "\f '^«'"" '"'"^ 

Mnnd  thesterno-cleido.mas.oid  o^^  h  ,  -j^':;!;'-  ,:''?'"'  ""''"""« 
lively  short;  thev  are  thin    ■m.l  fh/  '-'•i^'"  e.     Ihe  limbs  appear  rela- 

>lH'  limbs.  Hands  a^  t  '  rit"  "  nl'  '?"'  ""'  '"  ^'"'"^^  '''''^^  -- 
tlu'  hands.     Kigh,  wris    K'been  s      I  h""  ■''"'  ■■"""''  ''"''  '"  '"'''-^  <^^-- 

do-ninal  organs'do  no;  p  u  tl  b  1  t^r""?"  '''  '''''''''  ''''''■  ''• 
.dands  of  body  enlarged  UWht  Ijf  '  '^  '"  ""'  ^^'"-  ^^y'"P'i'"ic 
Ten.perature,  .;s.4"  in ';  ;um  n  L/"'"'^'r^  ''"""'''';  '«"gth,  .;„  en>. 
-'il'l  ^ay  ■'  mamma  "  a  d  >;„.'' t  t  :  .7  ,"""  '''  =  "'"^^^^  -'^^  '^ 
--.gh  for  that,     lllood  e.xi      nuio  1    'l  "  ""  ''"'  ''"^'"'■''-"' 

>ome  of  which  contain  pigmene'ln^^  'I';",""'  "*    ^"''"^  ^'''-'""^•"«. 

The  .did  was  under 'ot^i^i.^rir;:;:,''';;::'^^'-:;"""^^-  , 

with  .niinine  and  arsenic,  and  lor  a  while  .,nn«  .'  ^  '''"'  ^'■'^'^'^'^ 

'"  >i'  "|..  which  was  mor  than  1  ^  .;,,':,  '"  "  "7""'' '  ^''^  ^^"^  '''''« 
^Vhe.  h.st  seen  at  the  dispetKsa;y  iV  "  ,  t  ^^^TT^  1  '!"  "'■■^''""^'''•-- 
1.'^  hecn  gained,  and  was  prett/mucJr:,;  ;^:  ^^^l^  rt^''  "'^'  ^^'^ 

ihe  mo  her  sab    the  <l.il,l   i.„  i       .      ,,  ■  "^  "'si  saw  ner. 

tlH'  .i,ae  it  had  th  '  P  .  '.  t":  .:,^';;^  ^^r^'"  >"  ^'-  ''-t  year,  up  to 
ai'sulutely  no  growth.  '""  ""''■*^  "''f"^'"-"'  t"  I'ave  been 

('As-nV.     (J>r.  Kotchand   Dr.  J{ullard.)-G.K    female-  ......     ■ 

American,  i,arents   n<.t  blood  relations   nn^   ,1,         ,"."^'"'".^'  '^a'^'fl  **'x  years, 

'^''^'^  "'-'''^'  --lition  is  n.u  1  3ebld  ("•''■"■;"'  ^"'""-  '^'"^'^  "-^ 
4.i.^c,a.;  measure«,ent  Iron,  oci.m^tf  ,""''":?'"  "^' '''''  '''^'^"' '^ 
'-| 'nan  external  n.ea.ns  to  ext:!  ^  ^  ::  "r'  ^;^^":'  ^  -''-  '- 
^"""1"'""  <"■  inliltration  like  mvxceden.a  of  h'e"  k,  t>  '  "  "'  ^'''""'^ 
'>'^'  '"  be  felt.     Oircun.fere,.ce  of  ,h  r  x  i    4      ;       ,    V'"      ■''""  ^'""'  ''' 


I    i 


!  •  I 


I   ! 


I    ■    « 


ill 


-ii.-,4 


14 

She  is  S(). 5  cm.  ill  lipif:;lit ;  \veii:;lit,  41    poiinds.     Tlie   coinplexioii   is  sjilldw 
voice  (lisconliiiit,  liiirsli.     She  Micei)s  well;  is  good-iiiitured,  and  is  sel(liii:i 
uiliiig;  is  ;i  great  (iivorite  in  the  household.     J^iirgest  girtii  of  head,  ^)2  cm. 
Croni  iiosc  to  occiput,  :i")..">  cm.  :   I'rom  ear  to  ear  over  vertex,  "_'(!. 7  cm. ;  girtli 
of  iieci<,  :ili.3cm.;  girth  of  cliest,  ')4.")  cm. ;  girtii  of  abdomen  at  uml)iiicii>. 


Vw..  I. 


Fii, 


l^x^. 

1 

1 

4 

1 

^^^^^m*^" 

■'  1 

;    JP     « 

M\ 

Ca?e  V. 


■^unili  Mi<;.,  iii^cil  iiiiK'toiMi. 


(i2  5cm.  Tlie  abdomen  is  protuberant  and  tiie  cliest  is  narrow;  tiic  Ii'l:<  are 
perfect,  but  the  knees  incline  inward.  The  flesh  of  the  Inuuls  and  feet  imiks 
old  and  wrinl^ied  ;  the  teeth  are  a  good  deal  decayed  and  notched.  There 
seems  to  be  complete  atrophy  of  the  thyroid  gland  ;  there  is  fulness  in  ijie 
supra-clavicular  fos.-ite  ;  there  is  marked  curvature  of  the  spine,  both  hiieial 
and  anteroposterior. 

Ca.se  VI.  (Indian  School  for  Feeble-minded  Children:  Dr.  Van  Swcr- 
ingen). — f.ouisa  S.,  aged  fourteen  years,  horn  in  America,  jiarents  not  rehileil, 
no  goitre  in  the  family;  nationality  Cierman.  Height.  llo,.'i  cm.;  cir.iiiii- 
ference  of  head,  •')<)  cm. ;  from  occiput  to  root  of  nose,  83  em  ;  from  ixu-nial 
meatus  to  external  meatus,  2(1.7  cm.;  circumference  of  neck,  2S  cm.  flip 
skin  is  loose  and  flabby,  elastic  ami  soft,  very  abundant.  She  is  a  deaf-male, 
bill  ap|iears  ijuite  intelligent.  There  is  no  curvature.  The  tliroa.x.  i-  ■•!:■': 
cm.,    abdomen,    li'^.ii   em.      The    limbs   seem    a   little   enlarged   about   the 


iVlt  (.(•  the 


15 

.iei..::\o^rri;e:.;;S:!:M;:r^-':;r''^  -^'"^^'^""^ ^  '■^'-^^• 

put  to  root  of  nose  ;{•' r.c.n  •    ,!■  V<  '  '"«"«"'-e"'ent  /n.m  oeci- 

app-T  infiltrate.1  a„,l   n,vxc«d,.,„.Uo  h    .'n^M,  '  ^"'^"'"'''"^""'^  tissues 

,1,.  nan,™  „f „i,j„„,  „„j  „.„  ,„„;;;  j;;;;;^  »"■  i-  '>'-""y .bi,».  k„„„., 

...-rib;™,"  :::;■:  ,;7i',:  '";;:,t,r"™",''"""r ""  •■'""■■"«""'« '«"- 

ij.weiii,,B,iJLL:H    ;,'''■''■'  "t"'"  °'""  '"-""I"  si«"'i. 

.«.■."  ...';ye,  e4;;s::, '„'r,„t'''T;;"r^^ 

MuihM-  is  wrinkled.     He  is  imbeeile      tL    u         ,  •  ^''''  ^"^^  '» 

-e  n„  definite  tun.or  n.Mss  s  I  -e  he  I  "c  e' 'the  "'"'  ""•■"^^'-  ^"^^^« 
;^  -1  to  have  been  nu.ch  brighter  si  ';"::a.r  Th";;::  U  "'""'  '^^ 
lias  had  ..ccasional  epileptic  fits  "  '  ''"■^^^  •^'^'"''^  '»« 

""tat  all  bright  except  tba  1     ,1  ,'  ''»7^''.^^''''-^'^"'y '"telligible;  he  is 

-«. ,.n,c.,i, 4,s.4c,„. :  ,•,,„„  ,„,,„„. „,  „,:';,     «■■;;; ■:";:• -™;"""; 

niraiiis  t(i  external  meatus    ii  •',.,„      ^n       i-     •        '      ■  ■  ^"'- >  '">»i  t-xtenial 


i  ; .( Hi; 


,/' 


1 


u 

CcTfiirc  III'  (lie  llioriix,  .54,7  cm.;  of  iilMloim'ii,  ")1  iiii. ;  it  is  diHlinclly  |)i'iiilii 
loUH.     Siic  ciiii  (iiily  stiiiid  witli  ttHsistuiice.     Tlie  epipiiywes  of  tiie  liiiibn  hpiih, 
sdiiu'whiit  I'lilarjiicil,     Intcllifrcnce   in  extremely  .slijjlit,  imd  she   never  talk-. 
but  eaii  <'all   the  uariie  of  the  mir.xe.     She  is  ullectionate  in  disiioHition,  an. I 
on  recogiiiziiiff  the  Doctor  utters  i   peculiar  slirill  cry. 

The  Doctor  writes  tlmt  the  child  looks  about  tlie  age  of  three  years;  ,s 
uiuible  to  walk  ortostaud  erect  without  sui'iiorl.  'I'he  photo>;ra|di  illustrat.'s 
a  typical  cretin. 

C"A.SE  XI,  (Inmate  of  the  l.'al.iorniu  llonie  tor  Feeble-uiiuded  (,'hildreii; 
Dr.  A.  E.  Oshorue.)— I.  N.,  female,  aged  probably  thirty-live  years;  natin!. 
ulity  nnknown,  supposed  to  be  Irisii;  no  data  al)out  the  jiarenls.  lleiirln, 
JdS  cm.;  circumference  of  the  head  ."x)  cm.;  measurement  from  occiput 
to  root  of  nose,  35cm,;  circumference  of  neck,  ;{S.,'J  cm.;  circumfereiiie 
of  thorax,  .Sl.;{  cm.;  of  alidomen,  St  cm.  The  face  is  broad  and  llatleiicd; 
the  skin  rough,  and  hangs  in  fold<  over  the  body  •  the  complexion  is  sallnw; 
the  hair  very  scanty  and  coarse;  the  teeth  are  defective,  t)nly  half  aduzcn 
in  the  ujiper  and  lower  Jaws ;  ..o  thyroid  gland  is  palpable ;  the  spine  is 
slightly  curved.  The  intelligence  is  of  a  low  order,  but  her  memory  is  gcMnl. 
The  disposition  is  docile.  .>^he  is  tractal)le  iuid  allectionale,  and  forms  strong 
attachments.  She  is  quick  to  ajipreciate  ..  favor,  and  has  a  fair  sense  cif 
humor.  The  speech  is  slow  and  measured  ;  the  voice  ra^'er  low  and  i;i.p- 
ing.      llesi>iration  is  slow,  and  the  body  temperature  is  below  normal. 


!|i 


OPKRATIVi:    MYXCKDE.MA. 

In  coiiucction  with  the  subject  of  myxiBdei.  i,  I  am  indebted  tn  I)r. 
McGniw,  of  Detroit,  for  photographs  iliiistiating  the  followii:i,'  ca>e, 
which,  so  far  as  I  know,  is  as  yet  liappily  uiii(|iie  in  American  siii'<.'crv 
— niiraely,  one  of  operative  myxfvdeina : 

Cask  X  II.— The  patient,  George  M.,  is  now  about  thirty  years  old.  ami  was 
operated  on  .Mar  '■  7,  IS.Sl.  Complete  extirpation  of  the  thyroid.  The  pliotD- 
graph  [exhibited]  was  taken  March  liO,  IS'j.'i  A  full  descrijition  of  the  case 
will  be  published  by  Dr.  .McGraw.  Suffice  it  to  say  here  that  there  has 
been  a  gradual  but  jirogressive  change  in  this  young  man  since  the  ihitc 
of  the  operation.  The  hair  is  scanty  and  coarse;  the  skin  thick  and  roiijrh ; 
the  subcutaneous  tissues  very  thick  ;  the  integument  and  underlying  tissues 
nnike  great  ridges  on  the  back  and  on  the  hands  and  feet.  I'he  intclligenv.e 
is  good,  but  the  action  of  the  intellect  is  slow,  and  he  is  unable  to  dn  any 
continuous  work  or  to  sfdy.  He  complains  of  fulness  in  the  liead  and  ring- 
ing in  the  ears  when  he  stoops.  Even  in  standing  he  is  not  steady  on  liis 
feel,  and  has  a  tendency  to  fall.  Temperature  is  normal  ;  pulse,  70;  respira- 
tions, I'o.     lle.irt's  action  is  normal.     Voice  is  harsh  and  sipieaky. 


H 


ii. 


OF  THE  MEDICAL  SCIENCES. 


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.  'iiin'ls 
\iticles; 
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II' 1  such 

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r,  Thk  NKWshas 
,e  its  ii'.liiciionin 
heapc^t  ns  well  as 
11  the  ii.'Cin;ni2e(l 
3pon<letil,.|  special 
est  anil  \,c4  infur- 
of  mtdh  inij.  Its 
[he  most  atliactive 


<^  xxyv 


1 1 


NOTES  ON  tuberculosis! 
IN  CHILDREN. 


By  WILLIAM  f)SLER,  M  d  , 

Prole„or  of  Medicin. 
a.  .h.Mn.  Hopki„.Umver.i,y,  fl,|„„„,.. 


Kc.Kl    l,y   (itic    before    the 

Amkrican  Pkdiairic  Sociitv 
West  Point,  N.  Y.,  May.   ,893. 


Reprinted  from 

TifK  Archives  of  Pediatrics, 
December,  1893. 


i  pagt  ^  of  assorted 
1,  J1.J5.  Incom- 
vs,  \'isiT!Nii  List 


t 


M 

Iff  . 

NOTES  OX  tubj.:rcui. 


'■^JS   IN    CIIILDRKN. 


I5V    WILI.IA 


M    OS  LICK 


MA). 


Profe 


ssor  ol   Ar,.ili 


clne.it  If.,,  lohns  H„i,k 


I'kins  L' 


"uxTsity,  li.iltiiiior 


WHAT    IS    TIIK    INTiDi.- 


1"0L'.\I)|.I\( 


■<^l-:    OF   TVliKU 


ASVIJAis     A\ 


'•'I-OSIS    IX   THE 


I'lTALS    OF   Tins 


IJ     (-'HH. DKFX's     II 
COFXTRV  ? 


OS- 


I\ 


II, 

h 


preparing   the   artici 


intibook-  of  Childr 


o\v 


lew  obscrvatit 


ol  tub 


ren's  D 
lis  had  b 


L"    on    tub 
iseases,  I 


erculosis    for   Star 


r  s 


wa 


erculosis  am 


ilrcu  s  ji 


ong  tl 


^<^n  made  on  the 


■^  surprised  to  find 


ospitals  in    tb 


le  inmates  of  asvl 


prevalence 


tl'c    New     York    Found! 


s>    countr\' 


k 


ine 


i"*vn,  a  startlin 


H< 


xMortl 
'spital 


urns  and    cliil- 


ii'Lips   studies    it 


nou-c\-er, 


cluneal  and 


'^  prevalence  of  the  d 


^how,  as    is 


well 


published  d 


^ietailed    statistics, 
^matomical  obs 


the 


isease. 
result    of 


W 


e  miss, 


Gc 


uring  the  i)ast  fe 


servations. 


systematic 


cnn.in  colleges.     Tl 


w 


such  as   have    b 


een 


>'ears  by  oiu"    French    and 


are  tl 


lose 


fest, 


obta 


le  most   reliable    fi 


itions  are  so 


I'led  in  the  post 


post-morte 


gures,  of  course 


clinical  bt 


^UI)J)1 


protean  that 


m  room.    Th 


emeu 


very  many  tuberculous  1 


ted  b>' 


"ilc'ss    in    fatal 


'111  anatomical  e 


Tile  stud 


y  Would  iu)t 


iic'ctly  beneficial 
Kra.l  by  title  befi 


esions  are  overlooked 
>'ily  be  interest 


e  mani- 

<^"ases    the 

xamination, 


III    im 


proving    tl 


N.  v.,  Ma 


•%. 


ore   the   A 


"ig    in    itself,  but 
^iiitary  surround- 
"HT.can    Pediatric   So"ck■^^\;;;nw: 


le 


i/i 


m 


>/ 


/ 


2  OSLER:      Tuberculosis  in  Childn'H, 

iiigs  of  the  institutions,  promoting;-  tliat  scrupulous  clean- 
liness, that  aseptic  environment,  quite  as  important 
(though  we  are  apt  to  forget  it)  to  the  physician  as  to 
the  surgeon.  Whatever  stand  we  ma)-  take  on  the  quc-- 
tion  of  heredit}',  tlie  fact  is  indisputable  that  in  the  tuber- 
culosis of  children  the  enemy  in  a  large  proportion  ^f 
cases  enters  through  the  ever  open  portals  of  the  re- 
piratory  and  alimentary  systems.  As  the  surgeon  with  ,i 
case  of  streptococcus  infection  in  his  ward  knows  that 
there  has  been  some  frtcus  of  infection,  so  in  these  in- 
stances, when  we  lind  the  bronchial  nodes  or  the  mesen- 
teric glands  the  seat  of  advanced  disease,  we  shouid 
recognize  definitely  air  or  food  contamination. 

Attaciied  to  every  foundling  asjdum  or  children's  hos- 
pital there  shoukl  be  a  paid  pathologist,  who  should  i,  - 
port  yearl}-  to  the  Board  of  Managers  and  to  the  Medi.  al 
Board  on  the  prc\'alence  of  tuberculosis  in  the  Institu- 
tion. He,  better  than  an}-one,  would  be  in  a  position  to 
furnish  data  upon  which  important  sanitar\-  changes 
might  be  based.  In  ever>-  institution  so  ecjuipped  four  nr 
five  years'  work  would  not  only  throw  important  ligiu  ..n 
the  prevalence  of  this  scourge,  but  woukl  also  give  indi- 
cations as  to  the  best  means  for  its  prevention. 

II.     rnr,  fkvkr  of  tubkrculosls. 

The  second  point  requiting  study  relates  to  tlu>  fcwr 
of  tuberculosis.  Usuall\-,  w  hetlier  more  or  less  continu- 
ous or  definitely  remittent,  the  fever  is  associated  u  itli 
active  development  of  tubercles,  their  caseation,  soften- 
ing and  suppuration,  or  with  a  peri-tuberculous  pneu- 
monia. The  more  definite  hectic  or  intermittent  t\  pe  of 
fever  in  tuberculosis,  w  ith  intermissions  sometimes  List- 
ing for  man\-  hoiu's  of  the  twenty-four,  is  seen  in  elul- 
dren  as  in  .adults  only  in  advanced  cases  of  tuberculosis, 
In  all  these  instances  some  definite  relationship  exists 
between  t'le  severity  of  the  fever  and  the  extent  of  the 
disease. 

Our  French  colleagues  have    recentl\-  called    attention 
to  two  other  types  of  fever  in  tubercidosis   which  reipiire 


ilous  clean- 
important 
ician    as    to 
;i  the  ques- 
1  tlie  tuber- 
jportioii    nf 
if    the    re^- 
fenn  w  ith  a 
:no\vs    that 
tliese    in- 
;he  mescn- 
we  sliouid 


ti.e'n.berc^dolt!  ""^Z^  ^^1!^"''  ''''^''''''''  ^'  '^^-'-  '" 
--rityas    to    kill     bet^r   a   v  "";''*"""  "'^^    "^ --'J' 

profound  infection,  but  nf  ,,"^'^'' ''"  ^he  features  of  a 
t'-'vial  changes  were  found  eith  '•"'?'^'  "^^-^P^'-atively 
.^'ands.     This/.y.,w;::X;'-;^'-^'-.-or   in    the 

t-'se  tuberculeuse  surai.uJ      Is    U  "    ^^'''''    ^"^'^- 

^"  -  t'.c  monograph  of  Aviragnet      Th  '■"""'''^'  "^'"^■'■'•^-^ 
scnted  are  those  of  a  -ener-.I      7     •  '^y^Ptoms  pre- 

'"-■''  ^''-rder.  and  in  ?hcl,d  ,•[""?"    '"'''^^   ''''''    ^^y 
""  '-iciiously.  sometime!  '.  "  '^^'^'■''^-'  -    comin  ' 


""  '"sidiously,  sometimes  u-ith    v       v  '^ 

'•^•'i.  sometimes  dry    th,  V  '"'"'t'".^;  the    tongue   is^ 

"-■ntal  syn,pto,./;,e  ^^t"'  ""f  '''^  ^'-'■'^^^y  ^"^^5^;   the 

'-"•"^^p-    ^'-bdo;:^nt';us:ri°""^i- 

nd  snU ..,,       '"■''tended,  sometimes 


finind  depre 

p.iinful;  th.    i, .,•■--;  nnri        1         ""    '■ 

'      •-•  and  sn  foil  n.-.^  .  ■■.■^-o 

^--"Ptoms    are.  in  fact     those       r"''^"'"' ■'^^^'°"'^"-   '^"''e 
"■'thout  definite  local    s'io-ns  '   „  ,       ''    P'''*^"^'"^^    infection 
^^•'"■^■I>  the  disease  has  run     r         "'^'   ''^''^  ^-^^^nbed    in 
^-^   ^^y-     The  autopsy  ;,^::'"'  '"  ^^^''''-"  '"  a  verv 
lous   lesion,  perhaps    on  y^  t   e"  b  ^"f. '^''^''^  tubercu'- 
^r^all  area    of  tuberculous    K.        ,°"''"^'^'    ^^''''"''^   "'•  a 
'^'^^'^    -ay   be    con;;;:;:,  'r'^^'^-P"---"-.  or    the 
.-lands  in  the    mesentery  or    the    „e'ck''''°Ti;   °^  '"'''■^^^' 
Ha- beheved  to  be  caused  bv  the  tnl  ,       '    -^y^Ptoms 

"sua!  amounts  under  certain   f-,,        ,T  ^'""''^'"P"'  '"   un- 
-te  of  the  local  disease  ,f;''  '^°"''^'°"-^   ^'^   the 

stance  of  the    kind   in  clu'lcl re  ,    l"?T  "'"'   ^^■'■'''    ^'"    i"- 
-tted  to  my  wards  on  ]^    ^  ^  t''  ""^  ^^  ^-^  ^d- 
elieve  to  belong  to  this  t''%;;/''';^'^^'   '-t.  which    I 
'^-•ty-^c^-en.  had  a  swellin:.  on  the  I  TT'  "  *"""  ''^-''^d 
f"^]>  '--or  and  delirium.     He  h,  H^ad       %"' ^'"   "-'^•■ 
o'-  hvc  u-eeks'  duration.and   vd.en  '"  '"""'^■'^  "^  '°"r 

;■-   ^'x-e   of  a    mos         „        "/ 

''^'--al  disease   to    be    disc  """"    "■'^'o^'t  any 

..lands  of  the  neck.     tZuui:'"''   "'"'    ^^'-'^   «^  ^he 
^"?gesti^-e  of  typhoid  fever"],'      "^''T""""  '''^''    ^'^ShW  ■ 
'"ti-eck   sel-med    to    be    defir    '" V"    ^''^   ^lU 
'"-^'1    ""    the    fifth    day    'ft.:'"'^"'^^'>' tuberculous,       H 


iliei 


admfssion.     Th 


e   au 


topsy 


ttl 


4  Osli:r:      Tuberculosis  in  Children. 

showed  numerous  punctiform  h.xmorrhagcs.  There  was 
s  ,;hain  of  tuberculous  glands,  yellow  and  caseous,  on  th,' 
left  side  of  the  neck,  evidently  of  some  age.  The  kin" ; 
were  crepitant,  and  there  was  an  area  of  commcncii?- 
pneumonia  with  fresh  pleurisy  over  it  in  the  right  low^- 
lobe.  There  were  scattered  miliary  tubercles  through- 
out the  liver  and  the  spleen. 

To    another    form    of    fever   attention    has  also  been 
called  b)'  our  French  colleagues,  the  typho-tubenulosc.  .„■ 
continuous  tuberculous  fever,  acute    fever   developing   i,, 
connection  with  a  tuberculous    infection,  but   which,"!!,,- 
like    the    acute    miliary  tuberculosis,   runs    a    favoral)lc 
co..rse.     Apparently  it  may  be  one  of  the  first  manifesta- 
tions of  the  invasion  of  the  organism  by  the  bacilli,   but 
it  may  be  the  expression    of    what    may    be    called    an 
aborted    acute    tuberculosis,   consecutive   to   some    local 
disease,  and    Landouzy  refers    to    it  as    a  bacilliary  tox- 
-mia.   The  general  symptoms  are  those  really  of  tvph.,i,| 
fever,  from    which   the  diagnosis  may  be  extremely  diffi- 
cult.  It  runs  a  course  of  from  four  to  five  weeks,and  from 
the    description    and    the    temperature   chart  given  by 
A.viragnet  there  must  be  extreme  difficulty  in    its   reco..'- 
nition  from  typhoid  fever.     In  fact,  as  he  remarks,  when- 
ever we  find  a  child  with  a   cortt\i^rc   of  symptoms'  suffic- 
ciently  marked  to  make  one  think    of  typhoid    fever   but 
not  sufficiently  characteristic  to  make  a    clear   diagnosis, 
the  question  should  always  be  raised  as  to  the    existence 
of  tuberculosis.     Shall  we  then  recognize  an    acutely  <lc- 
veloping  fever  continuous    in    character,  associated 'with 
tuberculosis  and  differing  from  acute  miliarv  tuberculosis 
in  running  a  favoiable  course.' 


III. 


GEiNERAr.    ANASARCA    IN    TUCERCLLOSLS. 


The  following  cases   arc  of  special    interest    from    the 
fact  that  they  were  both  admitted  with  general  anasarca 
the  dropsy  being  due  apparently  to  the    blood    condition 
rather  than    to    any  secondary  nephritis   associated    with 
the  tuberculosis. 


riiere  \va^ 
ous,on  till 
The  killers 
mmcnciiiL; 
gilt  lower 
through - 

also  been 
rciilosc,  ur 
Jlopiny    in 
vhich,  un- 
favorahle 
nanifcsta- 
^cilli,   l)ut 
railed    an 
)me    iocil 
liar)'  tox- 
)f  tyi)h()id 
nely  (liffi- 
,and  from 
given  by 
ts    recoL^- 
^s,  wlicii- 

is  Sllftlc- 
fever,  but 

liagiiosis, 

existence 
utely  do- 
ted with 
'Cixiddsis 


SIS. 

roni  the 
.nasarca, 
oiuh'tion 
:ed    with 


^SLER:      Tul>ercufosis  in  Children 

Case  I. — (ieitei-y/  ^ 

::ra,u,iar  casts     „,!'''''"'■'■'"''  '''^""""'  ^^vW  kvnlin  •        ^ 
moderate  fc:  L^     f,    '"''"''   ^"^'K^h;  diff    /^^^    '' ,  ^'"^ 
""  Jt-^r,    death  01/   fl,^    f      J,  ".//"•*'    t'ronchiti^:  • 
adenitis    of   t'le    /,,■„„  ■/     /      f  -f^'O'tfi  day      Ti,/,  •.  J,     ' 

i  he  nature  of  thf  ■  >^cck: 

;;;•''-■'- -ithpnen;oni:-:;t!:'^'i^'^^'';  --^    «aid    to    be 
tl'cr.a   o,  ,^^   fever      At  t;r',^"'^^'''^"°therdfph! 

^cc-Mi.  tlie   child    v.as    wasted    •     .   f'^^P^'^^^O'.  uhc„  fi^4 
ai'<lomen  and  legs  were  su.  i  ^°°''«^   ^^ry  ij]      Th, 

l-cussion    note'over  !un.f  ?"'■  ^^fP^rature/ioio     ?L' 
heard  everywhere.  '""^^^    ^^^'^    ^^ear;  numerous  rdles 

Dr.  Booker,  who  hr^f  , 

culosis  and  sent  the  caseTfh       ''''^''  diagnosed   tuber 
f'lci  H-a.s  i„   ,    miserable   condi\?"'-    •?"  -'"^''■^sion  the' 
area;  closed  eyes   from  l^  i  '^'°"  ^ith   treneml    n. 

Ihc  cliild  coughed  frcque  ,    ,         ?  t^TOsions  on  the    1./, 
'''-,  .arge  from  ,l,e  mZh    ''  '  "'"'  ""=«    ""»»    a    WoSy 

'iiedon  the  fourth  dav.ff,    ^^'"^    '^'"'J^I    linjrered    -V    . 
^  ';ost.norten.  by  fe.  We;:-r'"i'^"",°"- 
era!  ana.sarca.     On  the  .W  s.    r  °''^' ^^  cm.  lonj.-  ^en 
'"■eg'ilar,  more  or  \&IV^         .^^"''ace  of  thifrlm   ni-mL'' 
fr-"  '"any  of  which  T  ^1;^^'^^  ---n?  oV'^r  Sn' 

'entoneum  cont-.;,,    i 
'--'  smooth  :n;rS    £,• 'r  ^'■•'^^^-  «-'^';  the  mem 

^'ots;  valves    normal; 


^'l;l 


Osi.ER:      Tuherculosis  in  Children. 


muscle  substance  pale,  and  fibres  showed  on  niicrosco])i; 
examination  extensive,  diffuse,  fatty  dej^enerations. 

A/^//i,'-v.— Left;  in  the  middle  of  lower  lobe  was  an  arc, 
of  collapse  and  a  few   spots    of  ccchvmosis.     The    uijucr 
lobe,  dark-red    in    color    and  solid;   and    at    the    inferi<.r 
margin  and  extending  to  the  middle    of    the    lobe    is   an 
area  of  solidification,  which  on  section  presented  casen'u< 
areas    surrounded    by   miliary    nodules.      The  bronchia! 
glands   were    large    and    caseous.     T'-e    right    lung  pre- 
sented a  ii^w  pleural    adhesions.     On    section    the   entire 
middle  lobe  filled  with  areas  of  grey  tuberculous  consoli- 
dations, in    the   centre  of  which  was  a  small  cavity  cmi- 
tammg  pus.     This  was  situated  between    the    upper   ami 
midtlle  lobes,  and   penetrated    the    tissuer    of  each.     Im- 
mediately below    this    cavity  and    adherent    to    it    was  a 
caseous  bronchial  gland. 

Z./.-Y7-.— Large,  pale  and  mottled  witli  areas  of  intense 
congestion;  the  lymph  glands  of  the  hilus  large  and 
caseous.  The  kidneys  were  large,  pale;  capsules  readilv 
stripped  olt;  corteces  wide;  striiu  clear;  microscopical 
examination  showed  intense  fatty  change  of  the  tubuK-^ 
particular!}- in  those  of  the  pyramids;'slight  degenera- 
tion in  the  vessels  of  the  glomeruli  and  granular,  fath' 
cells  within  Bowman's  capsules. 

The  Intestines. — Tuberculous  ulcer  in  the  ileum  just  at 
the  orifice  of  the  valve. 

In  Douglass'  fossa  there  was  a  caseous  mass  below  the 
peritoneum. 

Ca.SH  Il.—Prinia/y  tuberculosis  of  the   intestines:  dif- 
fuse tuberculosis;  general  anasarca. 

William  L,,  colored,  aged    nine,  admitted  October    r 
with  general  anasarca.     The  father,  one  brother  and  .,ne 


The   iiKJtlui 


sister  living;  two  died  when  quite    young 
is  dead;  cause  unknown. 

The  patient  had  whooping-cough  some  years  a"o- 
never  has  been  il!  since  that  time.  '^   ' 

Six  months  ago  the  present  illness  began  with  pain^  in 
and  gradual  swelling  of  the  abdomen;  the  appetite,  how- 
ever, remained  good;  bowels  regular  and  he  had  no 
cough.  He  has  gradually  grown  weaker  and  has  lost  in 
weight.  It  is  not  easy  togct  a  satisfactory  account  ol  Iii.s 
illness  from  the  friends.  The  condition  of  general  aMJcnia 
has,  they  say,  existed  for  several  months. 

Present  Condition. — Child  is  emaciated;  c\'e-!i(ls  (ede- 
matous; face  puffed;  mucous  membranes'  pale.  The 
hands    and     wrists    are    swollen;  the    legs    and  feet  are 


microscopic 
itions. 
ivas  an  aifi 
The    upper 
lie    infcriir 
lobe   is    an 
ted  caseoii>c 
'.  broncliial 
:    limy  prc- 
thc   entiif 
us  consoli- 
:avity  con- 
upper    ami 
^^acli,     Ini- 
)    it    was  a 


°'"''--      "-"""■"""Sis  l„    C,.i,.M:. 


'edematous,  and  tl,p  -.u  i 

Iiiorax. — The  '"ertasccl. 


luse 


til 


H.icla.„ecl  a„<l  i„|,„,.„;^ 


c'o^c   to   apex   were  two 
-^'     The  bronrhf",   ...^^^^'^'^   tuberculous 


'""^i  ^:''eesy  niass^'  ^' Th  r*-^-  P'^mented  'i^nf 
-!-  '-a    ulcei-s  in  the  iZ^y^^    "^^    "-    o,-    two   ...,, 
V"-  "<-''ii-t  was  noriml      ti      ■• 


'"'ffiit    lung 

"■'■as   at   the 

con- 

small 


;  1' 


!  m 


I-. 


I 

i 


8 


C)si,I';k:      Tuberculosis  iu  CliiUhcu. 


strippcil  ofCcasil)-;   sut)stancc  tiriTi,  [)alc;  the  .stri.r  alnm  • 
invisible;   no  tubercles, 

Inlcstini's. — "l'"ifty  cm.  below  diiocleiuim  was  an  c>. 
tensive  ami  circling  ulcer,  the  edj^^es  of  wliicli  were  un 
dcrmined,  the  base  irregular,  worm-eaten,  and  containrd 
necrotic  j,n-e>-  and  yellow  material.  It  extended  to  the 
muscular  coat,  and  the  peritoneum  o\-er  it  was  thick  .m,! 
opaque.  At  the  mesenteric  detachment  there  was  en 
siderable  thickening  and  infiltration  of  the  tissues.  Tlu~e 
girdle  ulcers  occurreu  at  vr  )-ing  intervals  througlu.;it 
the  small  intestine,  separated  from  each  other  by  a  {^w 
cm.  There  were  in  addition  circular  or  oval  smallrr 
ulcers.  On  the  peritoneal  coat,  corresponding  to  the 
ulcers,  were  numerous  nodules  of  an  o))aque  white  and 
yellow  ish  color.  In  the  cacum  corresponding  with  the 
mesenteric  detachment  was  a  closely  adherent  tuiii'.r 
mass  composed  of  caseous  glands  united  by  infiltrated 
fibrous  tissues.  The  omentum  was  adherent  over  this 
mass,  and  when  torn  away  the  underlying  tissue  crm- 
tained  large  and  small  tubercles.  The  cecum  itself  pre- 
sented an  extensive  deep  ulcer,  occupying  almost  the 
entire  mucous  membrane.  The  rest  of  the  large  intes- 
tine was  healthy  except  the  rectum,  which  presents  a 
small  ulcer." 

Peritoneum. — In  addition  to  the  nodules  corresponding 
to  the  ulcers  the  peritoneum  generally  was  sprinkled 
with  tubercles  varjing  in  size  from  a  pin's  head  to  a 
hemp  seed.  Between  the  liver  and  the  diaphragm  were 
masses  of  caseous  tubercles  and  tubcrcidous  granulation 
tissue,  and  tubercles  were  seen  on  corresponding  points 
of  the  pleural  surface  of  the  diajihragm.  The  mesenteric 
glands  were  enormously  enlargcil  and  converted  into 
caseous  masses.  The  retro-peritoneal  glands  are  al.>;o 
swollen  and  caseous. 


r 


\t 


y 


li. 


I 


■'  ! 


.yx  V  v';(L 


^ 


T()X/i:mia  rx  Tij'.KRrrLosis, 

IIV   Wll.LIA.M    nsl.KK,   M.I)., 

I'rtifisMW  tif  M.tliriiic,  Jnlui'i  f/ii/,/.  his  {'iiiiyfui/ii,  l:,ili:,„i,n, 

TliK  syinptoiu.s  of  a  profuiuul   iiiloxicntidii   in  tuberculosis  aic 
met   with  under  ilnx'v  eoiulitidns :    tiv.st,   in   tlio.xe   rare   cnsi'.s 
(lescribeil    nm.st   eoininonly   in  ehilclrcn,   in   wiiicii    iKnt'i    iii:i\ 
occur  witli  syinptonis  of  a   profound   toxieniia   betoif  tlier^  are 
any  extensive   localised   loci   of   di.sease.     "  The  ciiildren  Iiiivc 
presented  in  thi-  cour.se  of  tlie  disease  all  tlie  .sion.sof  aprofoiind 
intoxication,  and  as  tlie  tuberculous   lesions  of  tlie  lung,-*  .nul 
all  other  oi-o-aus  are  altogether  insufHcient  to  prnihice  deatli,  it 
is  quite  reasonabh'  to  attribute  the  fatal  results  to  the  bacillary 
intoxication.''  '     The.se  are  the  instances  of  they/tV/r  Ui/ntinm 
inhariiicusc   mruhjut.      Second,  acute    miliary  tuberculdsis  is 
often  accompanied   with  toxic  features,  giving  to   many  of  the 
cases  clinical  pictures  of  severe   typhoid   fever.     Pu&t  uiorlnn. 
miliary  tubercles  are  found  cxtens    -i;    throughout  tlu'  viscera 
and  on  the  serous  surfaces.     Thirc  in    hronic  pulinnnarv  tuber- 
culosis  there  may  develop,  with   oi    witlumt   fever,  a  profonml 
toxiBUiia,  with   dry   tongue,  delirium,  rapid   pulse,  and  siyns  of 
intense  intoxication.      The  patient  may  be  admitteil  to  hospital 
unconscious,  with  a  normal  or  .subnormal  temperature,  ami,  as 
in  a  case  which  was  under  my  care  at  the  Philadelphia  Hospital, 
the  autopsy  alone  reveals  the  true  nature  oi'  the  disease. 

The  following  case-  may  perhaps  be  regarded  as  an  instiiuci' 
of  the  fchri^  Uthvrmlosa  iieracuta.     The  striking  features  wort- 

'  Aviragiiet :  Do  la  Tubercnilo.su  cliez  le.s  Eiilant.s.     I'aiis,  ISl'-J. 
I        -  Repovteil  in  the  I'hih'ideliilii.i  Maiicul  Ncks,  December  2,  1S92 


'""'^■''"'"    '■"^""■^'■^v   i"  tlu.   live,     t  ^      '■•^ercuiosis    of    verv 

'^■'t  «'do  of  the  neck,  euu-l.   ,„  .      '    '•''V:'^''  •''  -^•'"ing  in  ti.. 
•^<'f'"-"g  very  .l.-finite     i,     1         7''"^'^^' "'"1 -'^'Imuu,. 

for  about  two  weeks,  .n.       ,       ^   ":'^''  ^^    "'"'"-•  previously 
H^'  '-Ioe,usio„.|lvl',.u,,i,,';^  '  ,;'  •^••"•;     '"  tlK.  ab.Iom.„. 

f'-'''i'':'-iin.s:.u,'r    ^^^^^^^^ 
>t^vas„ot,ee.ltl,attl.o..l.uuk       Ti        r  '"'^  "   "-^'^'l^   '''te.' 

«-e>ks  before  presontin,  iZ^^u      ,7^ '    ""'-'•   -til   tlnee 
^"""fing,  but  tbere  was  loss  of '.,'   V ''       '.'"^''"'  "'"'^^^'^   "«'• 
ness  and  fever.     For  fully  two  wj  iT      i  "I  ,  '"''^^''-^^i^^  ^^oak- 
f  "i^'-t  qnite  .ielirious:    TWd '^  T    "    '*"' ''■"'''^"^'' -"' 
-'"'.^of  profoun.l  weakues.     ...  '   ""'   ''•'^^'   '''^^'»   t^'^' 

''^;_^--«..eun.be,;:oS:^ 

Oil  admission  the  Dationf  K  i     . 

-''-^•r^androse^^^V    t'  (;?'":"=  ^''^^-1-^ 
'^•'-e   the    ten.peratnro   h.i    .!      ,  /      ^^'™"Sliout  the  day 

''-'-'  '-db.Ldelirio:''^^^^:-^^^^ 
""""^^'''-^•l  "^an,  and  di.l  not  look        Y    '"     ''''"  ''    ^''''•'.^-  ^^ell 
^-t  length  of  time.     The  c^,!  '  ''"'  '^^"  ^"  ^'^  -'7 

-''  --us  nien.branes  w4  Xr  7''^  T'^'  '"*  ^''^'  ''l- 
"■^'f  ofniediuiu  sixe  and  rot  V  ,  "^^."^"^^  ^^''""••.  The  pupils 
^-'-     Thetongu;   irS"   f^^  there  was  n^  :;;;!: 

-  -Pid.  124.  regular  but  s^r  ,  ^  II  "l^*?"     ^''«  P"'- 
Tlie  respirations  were  a  little  Inirri  '^'^'^^'.'^''^  compressible. 

"^  ^''^^  -■•'»  di<I  not  show  ai  y  m       '',       '^'-^'-^  *«  ^Jie  minute, 
Kvconifortably  uith  his  head  lo'y  '"'^^P^-'^tory  distress,  and 


r 


). :  ii 


«■     ! 


i 


tti 


28 


toxj:mia  jn  tuberculosis. 


size   of  a  horse-cliestnut.      There    were    no    other    lymjiliatic 
enlargements. 

The  chest  was  symmetrical,  the  expansion  otinal,  and  thore 
was  no  change  on  percussion  ;  the  respiration  was  everywhere 
clear,  with  the  exception  of  a  few  sibilant  rales  at  the  h:isc:<. 
The  expectoration  was  muco-puriilent,  small  in  amount,  slightly 
blood-stained,  and  repeated  examination  failed  to  discover  tlie 
presence  of  tubercle-bacilli.  The  heart-sounds  were  unini.il 
and  there  was  no  increase  in  the  cardiac  dulness. 

The  abdomen  was  symmetrical,  full,  and  generally  tympanitic. 
The  patient  had  live  movements  of  the  bowels  in  the  tir^t 
thirty-six  hours  after  admission.  They  were  soft,  but  imt  in 
any  way  distinctive.  The  edge  of  the  spleen  could  bo  oasily 
felt  and  extended  three  lingers'  breadth  below  the  ostd 
margin.  The  urine  was  dark  reddish-brown  in  colour;  GGO  cm. 
were  voided  in  the  twenty-four  hours,  containing  a  sinall 
quantity  of  albumen  and  a  few  granular  and  hyaline  ca^ts. 
Tiiere  was  a  decided  diazo-reaction.  The  patient  was  irrational 
and  frequently  spoke  in  an  irrelevant  manner. 

On  the  15th,  two  days  after  admission,  the  patient  was  sIjowh 
at  the  clinic,  and   I   extract  the  following  remarks  froui  tlic 
report  of  my  stenographer  :    "As  to  the  nature  of  this  inter- 
esting case,  from  the  appearance  of  the  man  and  the  history 
you  would  think  at  once  of  typhoid  fever,  though  the  tempera- 
ture-chart is  unlike  this  disease   in  the  fourth  or  iifth  wviAi. 
Still    the   general    features,    the    enlarged    spleen,  the   diazo- 
reaction,  and  the  negative  condition  of  the  examination  reud'T 
this  diagnosis  highly  suggestive.     Against  this,  however,  tlieie 
are  several  important  objections.     The  tempo rature-rano-e,  as  I 
have  mentioned,  is   more  contiirrious   than  is  usual  in  tvplioiil 
fever  at  this  stage.     The  abdominal  .symptoms  are  .slight,  and 
there   are  no  roso-^p  ts,  though  it   is   true   the   spleen  shows 
marked  enlargement.     Bronchitis  is  not  an  infrequent  compli- 
cation of  typi  .id,  and  at  the  bases  it  is  of  course  common  to 
have  diffuse  rales.     A  feature  that  suggests  another  diaonosis 
is  the  talargement  of  the  lymph-glands  on  the  left  side  of  the 
neck,  which  has  increased  during  the  patient's  illness.    Then' 
can  b'.   no  question  that  the  enlargement  liere  has  nothiuo- 
whatever   to   do    with    the   ordinary   swelling  of  the  salivary 


Tox.r..u,A  IX  rrnEHcuLom. 


^.aiids  seen  in  typl;oid  fever.     Here  tl.r-  nW.  f       •        •        "'' 
iH  the  lympLatic  oj^.ud,  ^,„]  „        "^  ^^"  '^^^•^^'on  is  evidently 

suggests  rather  that  the    n   e  t   "    "'?""^T'  ofthe  spleen, 
other  points  of  interest  ,vK?  T^  tuberculosis.     Tu-o 

sh^nvs  a  niarlced  di    in   tie    in  T''     ''"  blood-count 

2,000  per  cn.n.bei.;;:::\in:'t'^''  "^  '--y^es,  only 
tuberculosis.     There    ^l,  ,       .  '     *'''"'''  '■''^^''^'-  '-^S^^-'St 

tubercles  in  the  Choroid.'         "'^   ""'""^   '^"''    ^'^^    -«   '"^ 

Till-  oritical  condition  of  tliis  i,-,fi„„,  ,.  .  ,•        ,     , 
the  16H,  and  I7tl,    T|,o  tonme  -,  ,:'"""'  ""-""S'""" 

rardy  falling  below  lols'T    ;:'',:  '"'''' "•'•'"  »»" 

':»■"  HO  to  l,i„ ;  the  aWotnen      J    :  ,i   r::;  ■  '7°   "'"''' 
tions  very  sli.illow  and  ,-,„i.l  i  ..        '"*'^""ou,  tlio  n-»jura- 

morningof  tiuastl         '      '      '     *°  I'""™' di"''  early  oi  the 

s.,b™ta„eo,.  in,.,„o,,.i,a;*;:  u  :  t':;:,":,', ■;::'■"■;" 

sule,  as  also  lu-eniorrhaoes  in  thp  «„!.     /  .  ""  "^''^ 

situations.      The   nruscFr   ve.f  of        dr^"^,  ''\''  '''^'''^ 
peritoneunr  was  smooth  ■  the  dLbr  ^"?     '''""'"•     ^^^''^ 

at  the  ilfth  rib,  on  tl.  iJl^  «'  ^     i:  ?"  '"  "=''^  ^'''^  ^^ 
sixth  rib.  •'*  *'"    "I'l''^''-  '"^^'-gi'i  of  the 

Both  layers  of  the    pleura   were    united    bv  obi      ii     • 
some  of  which  were  pigmented.     The  lu  '      tl         T        '"'' 
crepitant  and   deeply^ig„,ented;  U.  ^  t^t^'  ^"" 
gested,  and,  on  section,  serum  and  blood    scan,        ;"   ";'" 
contained  frothy   mueu.        Aln.urfl  '' "•     ^''^' bronchi 

right  lung  thepleura    isot^L  ;;n"'^^   ''"^    ^'  ''''' 
in  thickness.     Beneath  it  the   n       ""''''."''^''  '"^'^''^I'nng  .S  mm. 

^'•^eoahe  right  i;:g'^.:::j:^:^^f-^^^ 

ana  the  pleura  was  covered  with  ^Lh  o.^    ,  T       'n'" 
section  the  Iun<r  wis  dpon  r.     ■  .  ■  °''^""''^'   ^brin.     d, 

excised  sank   i^  To,      'v    1^  rt  "' r'"'";:""'' P-*- 

T'"  f  *»"* -s  -,oo.,;:,„f  ir',f:  ai  ■  V"',""'"'- 

n.«.clc  was   soft    and  s„„,ewl,at    friable       Tl  I  lu  T' 

!,»5(lsramnies;    tl,e    sarf.eo   w,.  \,  ■-'''  "'«'""' 

"i*i*  »..j  'vi;itisi,.yei„r„ ,,,"';:''';  .""V'"^"  "■'- 

apsui...  irre^nlarly  soLor-d        l7„,         "'■""'    ''';"-^"'     ""= 

and   not  in  great  nunibc 


!    'ill 


nbcrs. 


Tile 


I'm 


I 


.30 


ro.X.KMIA    IX  TUltEncUI.osis. 


spleen  vvei-hecl  .lOO  grammes  ;  tlie  section  was  .lark-re.l  i,i 
ooloiir  ;  the  brown  pulp  was  abuii.lant,  and  there  were  nu,u,.r- 
ous  large  tubercles  in  its  substance.  Tlie  kidneys  present^,]  a 
ieu- atrophic  patches  in  the  cortex;  the  striie  were  coarse  md 
pale ;  the  consistence  a  little  firm.  There  was  notliin.r  of 
special  note  in  the  pharynx,  stomach,  ,)r  u3sopha<.-us  Pove,-'- 
patches  were  a  little  swollen;  the  mucous  membrane  o(^  the 
intestines  was  somewhat  congested.  The  ^ ' i^j^cidic  v,r.,nfn,;,,i, 
was  obliterated. 


I !  ark-re' 1  in 
wore  nuDiLT- 

pre.seiiteil  a 
'e  coarse  ami 
>  notliiii^f  lit 
;'us.  Peyec's 
)raue  of  the 


r    !l 


I  >  I  ,1   I 


<BPK1>       ED  KROM 


UNIV 

-RSITY 

'OICAL 

Magazine. 

KIM  V. 

tnr 

:.  STAFF 

J 


IjANUAIn'  .  ,   1884 


FAROTITIS  IN  PNEUMONIA 
"SE  O.  Pi^HICAHBITlS  TREATED  BV  INCISION 
AND  DRAlNAGli. 
By  Wiluam  Osler,  M.D., 


/'^m^r  0/  the  Theory  and  Pra. 


Johns  Hopkins  Medical  Scho. 


ctice  of  Medicine  in  the 


'ol. 


IWUm  II  II  i'».    ■«      ^    iiii    ,1 


I" 


».■«' 


;l 


THr.  ..    '^^''''''''^  ^N  PNEUMONIA 

This  complication  iq  of  ^  • 

the  Montreal  General  HspLTwhrh  T'^"     '  ^^'"^^^  -  case  at 
^n  th,s  disease,  nor  was  there  ,nfn.  '"  "°"«"^-»»y  large  service 

the  disease  Which  I  performed  ."^^Ln'^^  "^  ^°^^--^^^^^^^^^ 
ess  frequent  than  endocarditis  or  ,...  '"'*'^"^'°"-  It  is  very  much 
has  in  one  or  two  instances  Itn  1  ."''"'°^'^'«'  ^^'th  which,  howevTt 
in  which  in  the  course  :;rabr::loll  ^""'^  --^ions Tc^;;; 
parom.  developed  on  theforty./ftrd  !    t^r"?  P"^"--"a,  double 

The  following  is  the  nni  ^ '  ^^  P^^»^»t  recovered 

personal  observation  The  c  'diac  ^  "'^^^  ''^^  come  under  mv 
great  interest,  inasmuch  aVthee  J  "'  ''^"^  ^^^^^  ^'^°  «  ve^v 
pericardial  friction.  '^'''  ^^«  ^  very  well  marked  pleuro 

P.VHrMOm.OK.HRUPPHKTHZKr>OKXHHln 

;--•  "tL  mie:^:^tlZ^'-f^^  Hospital,  October 

elmous  no  history  could  be  obtaTn  d     The  t  "'''  ^"'  '^  ^^  -«« 

at  4.30  I'.M.,  was  10,"  .   r,„l««  ^  temperature  onadmisMnt, 

«'«-"nirt.a„dif„srared,^tai  ?""°"-  ^^     He  1:^; 
iiivolunlarily.  medicne,     feces  and  urine  „e„         J 

October  30    i   p  jj      ,.1^ 
delirious;  tongue  dry  i  'h  a  nd^  tremulous  aT  "  '°"°"«  "^    ^^^ient   is 
^edcothes;    pulse    r.o,    feeble      re  ^LTo^"'"'"''^  ^ 
Expansion  on  the  left  side  is  defecuir     .  ^t'    ^^'"P^^^ture    103° 
tyn^panmc  note  from  clavicle  to  sixlh  rib  ''''''  ''  ^  "•^''  marked 

«te„d>ngfrom  near  the  spine  of  tt  '  ^f'^^^^^y  ^here  is  dulness 
-to  the  posterior  half  of  th'e  xiHa  or'f  ''""'^^  ^°  *^^  base  and 
-ds  are  tubular,  with  rales  ^thee„d  of  '""•  "^'°"  ^^^  ^-^^h 
breathing  :smtense  at  the  angle  of  scapula  r,  '"'P''^^'°»-  blowing 
The  heart  sounds  at  the  apex  are  clear  ^''''  '^  "°  expectoration 

-Pe^r  ^:m  ^^:;:-^  -;;;  - -:- ;^P.ation  ,.  to  , 


'  Gtsa: 


'""lelte  Beitr.ige,  l)d. 


"■  Article  20 


"-US  and  has  had  very  littl^ 


I 

r 


^ 


2  Parotitis  in  Pneumonia. 

sleep.  Takes  medicine  and  nonrishmeut  well.  Has  been  taking 
carbonate  of  ammonia,  aromatic  spirits  of  ammonia,  whisky  and 
strychnia.  The  patient  is  decidedly  worse.  The  pulse  is  more 
feeble  and  the  skin  looks  now  a  little  bile-tinged.  He  is  still  delirious;  it 
was  noticed  this  evening  that  the  left  parotid  gland  was  swollen.  The 
bowels  have  been  freely  moved.  The  physical  examination  gave  the 
following;  Left  lung  clear  to  lower  border  of  fourth  rib,  below  which 
there  is  duliiess.  There  is  a  loud  friction  murmur  and  many  rales  in 
left  axilla.  Below  the  third  rib  and  to  the  left  of  the  sternum  there  is 
a  well-marked  pericardial,  to-and-fro,  friction  murmur.  It  is  not  heard 
at  the  base  and  is  loudest  in  the  fifth  interspace  below  the  nipple.  It 
was  concluded  that  it  was  pleuro-pericardial  friction.  The  condition 
at  the  back  of  the  chest  remains  the  same. 

November  2.  Temperature  through  the  day  has  ranged  from  102^ 
to  103°  ;  pulse  from  126  to  130,  regular  and  small ;  respiration  44  to 
52.  Examination  showed  blowing  breathing  outside  the  nipple  line 
and  in  the  scapular  regions  rales  were  numerous. 

At  the  apex  both  sounds  were  heard,  a  soft  systolic  murmur  with 
the  first.  Sounds  are  clear  at  the  aortic  cartilage.  The  to  and  fro 
friction  in  the  fourth  and  fifth  spaces  is  scarcely  audible. 

November  3.  The  patient  passed  a  fair  night,  slept  better.  The 
parotid  gland  not  much  swollen.  Temperature  102.9°.  1'he  apex 
systolic  murmur,  which  is  much  more  distinct,  is  not  heard  in  the 
axilla,  but  is  much  intensified  towards  the  sternum.  The  sounds  are 
clear  at  the  aortic  cartilage.  The  murmur  is  loud  in  the  third  and 
fourth  left  interspaces.  The  pleuro-pericardial  friction  sound  has 
entirely  disappeared.  The  percussion  note  is  clear  to  the  uppe^-  border 
of  the  fifth  rib  ;  it  is  dull  from  this  into  the  axilla. 

November  4.  The  patient  is  weaker;  pulse  130  to  140;  tremor 
is  constant ;  respiration  44  to  56.  Passes  urine  and  feces  involuntarily. 
The  apex  systolic  murmur  is  distinctly  louder  and  rougher  than  two 
days  ago.  Sounds  at  the  aortic  cartilage  are  clear.  There  are  11c 
cutaneous  ecchymoses  ;  no  sputum  has  been  obtained. 

Respiration  65;  pulse  160;  temperature  103.6°.  Death  took 
place  at  12.15  p.m. 

Autopsy,  twenty-four  hours  after  death.  Body  that  of  a  small, 
moderately  muscular  man  :  skin  slightly  icteric  ;  left  parotid  swolleii. 

Thorax  :  A  pint  and  a  half  of  seropurulent  fluid  in  the  left 
pleura.  The  upper  lobe  of  the  left  lung  is  glued  to  the  pericardium 
by  thick  fibrinous  exudation.  The  entire  pleura,  visceral  and  parietal, 
is  covered  with  a  very  thick  creamy  material.  The  right  pleura  is 
smooth. 

Heart :  The  pericardium   i.^  smooth  ;  no  exudation.      The  right 


Death   took 


Pfficardiiis   Treatrd  /,,.   a.  •  ■ 

eatcd  by  Incision  and  Drainage 

chambers  are  dilated  and  full  of  rlnri,    r 

drawn  from  the  vessels.  No  endocardiii«""A?°'''  ^^'^^'  ''"  '^"  ^''J'- 
what  relaxed  and  turbid.  The  .X  '  -.'^"^^"^'^^  ^"bstance  .some- 
the  „„ddle  of  the  second  joint  "^  '^""'^  "-^'^^  ^"ffers  to 

airlei^a.:;i: Jl::  ^  '^[r^e:'^ J^^"  ^°^^  -e  collapsed, 
nently,  is  verj.  firna  and  in  a  conditio   ,  f ''"''  °"'  ^"^  ?">»"■- 

bronchi  of  this  part  are  filled  vv,T  ''^"''  '"'  ^^^P^^^^ation  The 
lobe  is  crepitant  throughout  trd^r?"  ''"'^'■°"-  '^^^  "PP- 
"ot  contain  much  blood  or  se  urn  T.  ^^f'' '' '^^ '^^«^'  ^"tiid 
tbe  ba.se.  The  bronchial  gla  d  are  el"'  .'  '""^  '^  ^^"^'^'^^^'^  «t 
^spIeen  .s  enlarged  and  soff  and   cont  f     ""^  '"'"^^^^'-      '^^^^ 

■nrarcts  with  yellow  brown  loTL^^Tix^^,  '"^^^   ^^^-^^aped 
turbid;    no  infarcts.      The   liver  n  ^^'"^  ^'^"^^'S  are  swollen  and 

swelling.  The  stomach  s  sm\,  -The  .  ^'^  '"°''^'^"  °^  <^'-'^y 
bowel  presents  patches  of  deep  „g  ',  .r^^If^  ^-^^ ;  the  large 
eeply  congested;  the  interlobular  en, '•  «^^  '^^^  P^^-^^'d  gland  is 
here  and  there  are  distinct  focfof  PUS  %\'"f'.^^^^  with  blood  and 
changes.  °'  P"^-     The  brain  presents  no  special 


CASE  OF  PERICARDITIS  TRFATi-^r.  .. 

AND  DRA^^OE        '"^  '^'^'^"^^' 

J'!!^.''"-^nracut'  (0  Aseptic  pericar- 

ehnum  occasionally  seen  with  pedca  dia    eff  "°'' ^  ^^^  ^^^  P^^"^'- 

two  weeks  after  operation,  when  C  mH     .  I  ?°°  '    ^^'^  '^^  ^"•'^et, 

excessive  cardiac  debility/problirdurtom        '.'"'^  '°^°^ -"'  ^^ 
January  ic,  rgon    t  c/  ,  °  myocardit  s. 

few  days  before  the  New  Year  he  ''''"'  '^^"'''^^'"^-^  ^^  ^'^  ^-^e  'a 
;tich  became  acutely  infl!m  dt/f^^l!'  '^^V""'^^  ^^^^  ^-  -.e 
fetor  m  the  secretion  Dr.  Donaldson  T  u  '°^  ''^""^^  ^^ere  was  no 
was  present.  A  week  or  so  befJre  l^'^u-  ''"'  ""'''''''  ^^  ^he  bones 
;ortofbreath.  the  fever,  wLHt/b:::'''^  '^  began  to  get  a  litt  e 
'l^ere  were  signs  of  con.,.>ion  at  the  b  7^'"'  ^'''"^^  ^'^SK  and 

pulse  became  much  mor^^  P^d  a^,H  r  m '''  °^ '^"  "^^t  lung  The 
^'"^t.  When  I  saw  him  the  condition  '  '"'  *^^  ^^^^^  «°""d«  indis! 
;P;nbed.    Respiration  is  noisr^rtt-?'-'^"'""-  ««  sits  propped 


i  i 


4  Pericarditis   Treated  by  Incision  and  Pminage. 

breathing  r-omes  from  *'        i  '  both  nostrils  are  obstructed.     The 

pulse  is  no,  irrorn'.P'  in  vo!mie  and  in  force.  Heart;  inspection, 
nothing  noticeable,  .is  a  lieavy  layer  of  panniculus  covers  the  mammary 
regions,  no  impil-ie.  No  thrill.  Dulness  extends  to  upper  border 
of  the  third  rib  in  parasternal  line  and  to  .1  level  of  the  second  rib  on 
the  sternum  ;  to  the  right  it  reaches  two  fingers'  breadth  beyond  the 
sternum  ;  to  the  left  at  least  two  inches  beyond  the  nipple  line.  On 
au.scultation  no  heart  .sounds  audi'  ■  \  ..  ^.iv  of  heart  or  towards 
apex.  At  the  base  feeble,  distant,  only  just  distinguishable  sounds 
can  be  heard. 

Pes(<uance  is  impaired  at  the  right  base,  and  there  are  here  rales, 
but  no  pecial  blowing  breathing.  In  the  left  lower  axillary  region 
there  i?  a  flat  tympany,  a  modified  Skoda 's  resonance. 

It  was  thought  from  these  signs  that  pericardial  effusion  existed. 
Til  ne  was  albumin  in  the  urine,  but  no  lube  casts.     A  remnrka!)le 
form  I  f  delirium  was  present  ;  he  would  talk  quite  rationally  for   1 
time  and  then  wander  off  on  subjects  connected  with  his  business,  and 
never  seemed  exactly  to  know  where  he  was,  though  he  always  recog- 
nized his  father  and  his  wife.     I  saw  I  m  again  on  the  17th  and  on 
the  2ist.     The  condition  remaini.d  practically  the  jame.     Puis    -..as 
extremely  irregular,   feeble,   112  to  120.     Temperature  rarely  above 
io'°.     Respirations  from  35  to  45.     He  could  not  lie  down  and  the 
color  of  his  face  was  certainly  worse.     Physical  signs  persi.sted  un 
changed.     There  was  an  entire  absence  of  heart  sounds.     The  dulness 
had  certainly  extended  more  to  the  left.     On  the  2 2d  Dr  Halsted  rut 
down  into  the  fourth  interspace,  midway  between  nipple  and  sternum, 
and  after  aspirating  somewhat  over  a  quart  of  .i  sero-purulent  fluid. 
incised   the  pericardium  and  inserted   a  gauze  drainage  plug.    The 
patient  stood  the  op*,     "'on  v    y  well.       he  area  o*" dullness  diminished 
remarkably ;  the  heart  sounds  were  better  heard ;   but  there  persisted 
in  the  fifth,  sixth,  seventh  and  eighth  interspaces  outside  the  left  nipple 
marked  dullness  as  far  ua  the  mid-axilla      The  imp    vement  after  the 
operation  was  rapid.     The  pulse  the  following  day  was  steadier,  w'th 
only   an    occasional    intermission.      The    Icirt    sotirds   were    n.ore 
clearly  heard    and    the  area  of   duUne.-,  still    further    diminished. 
The  drainage  was  very  free,  soak-        the  thick  layers  of  gauze,    On 
the   third  day  the  dullness   wat      jS        irked  iu   the  a  a  ilia.      The 
note   was   here   somewhat  tympa     tic.       The  peculiar  delirium  per- 
•^isted.      Temperature  fell  to  normal.     He  took   his  food   well  and 
gained  rapidly  in  strength.     On   the  eighth  day  the  discharg-    had 
become  verj'  much  less.     The  opening  was  still  free.     Dullness  had 
diminished  very  much.     On   the  tenth  day  after  the  operation  the 
following  note  was  made  : 


Pericarditis   TreaUd  lu,  /...■  • 

created  by  Incision  and  Drainage. 

February  i.      Patiptii*  ,e 
jead   low.   breathes  wU     J    SuUrT''^'  ^I^^^^  "^  -»^  fa- 
Pulse  ....  regular,  of  fair  volume      ^1  r.^'^' •?!'""'   '^^  ^^°"t  30. 
(Kscharge  soaking  the  inner  dressine      oL"  ''       '""'^"^'"  P"^"'«"t 
or  palpable.     Dullness  begins  tt  2'  I  T  '"P"'^"  '«  "°t  visible 

right  margin  of  sternum'  t      L  lef  T',  ""T^'  "'  '''"'  "^  and  at 
nipple.     Auscultation  :    F  rst  and  sectnH  /'  ^'"^"""^^  ^'^^  the 

urdiac  regions,  still  a  HtUe  dhtant         '°""''  '^'"^  everywhere  in 
friction  to  be  heard.  "* '  "°  '""rmurs.      No  pericardial 

clearitThV  left'L'se'and'in'  [hrioT     ,'V''  "^'^  '^^''^  ^''^  ^^les. 

nonual  than  it  has  been.     DdirutC"    I    '""^  *^^  '^"^^  ^  '"ore 
February  6.     Patient    TJ    Tu         °*  ^''"  P''"^"'  ^or  some  davs 

There  is  no  f^ver.  but::  u  se'co::;:;::^"-  ''''  ''^'^'^^  ^^^ 
more  irregular.  He  is  also  very  restles  "T  "?  ''"''^  '"'^  ^^^  '^^^°">- 
hypodermically.  There  was  ap'are  ,,  itv  T'  "^"'"^  ""^^P^^ 
du.  --ss  to  the  left,  but  Dr  Hals^eH         ,^  '^^^  extension  of  the 

the  p  ricardium  and  there  see™  d'  b!  no  '"'  '"  '°^^^  ^^^  -'^hin 
fon  'te  heart  sounds  were  clear  but  ,  ?''°°  '°  ''"  ^  reaccumula- 
February  7.  Patient  has  fllVran  h",  ""Z  '''°"^  '  "^  ^"^'""r- 
ular  and  f.  .A..  Great  restleTsne  1  Cnf  ''•  "^"^'^  ^^^^^'^'^^y  ^^reg- 
more  hurried.  P.-bruary  8.  Tsan^a;;:!-^^  T''  ^^P-tions 
autopsy.  ■"*  '^""^  and  died  this  morning.     No 

William  Osler,  M.D 

t^    Z''"  ^'"  Mns  Hopkins 
Medical  School. 


/.]  '1 


t 


Fro 


^1 ;,  I  < 


L-GETOAL    mrSIS  AND  SUMMARY  OF  239 
CASES  OF  TfPHOID  FEVER. 

II.-THE  TREATMEST  OF  TFPHOID  FEVER. 

m.-A  STUDY  OF  THE  FATAL  CASES. 

IV.-SPECIAL  SYMPTOMS,  COMPLZOATIONS  AND 

SEQUELAE. 

By  WILLIAM  OSLEE,  M.D. 


I|  ' 


!       '■  i; 


'I'       I 


^  tU  John,  MopUM  Eo^ua  S^^,  Vol.  IV,  m.  1, 


■Baltimore,  M4, 


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J.— GENERAL  ANArv«JT«   a  x^t^  ^ 


Bv  WILLIAM    OSLER,   M.  D. 


To  May  15th.  ISQS   ooq 
n.edieal  warcf.  '        '"  ^''  ^''"^  "^  ^-^•P^-'l  '"-.r  .ere  treated  i„  the 

Tlie  patients  are  isolated  in  Wnvd  T       i       ^ 
or  for  some  special  reason  '  ^^  ^'  ''^'°  violently  delirious 

Th   vcrylarse  pr„|,„rti„„  offt,,.,™,  "??        '  *■■■'""  '-  *^'™  1- 
!.«,c„la,.|.v„fQe,,„„„,,.  „„j  J,;  ;';''"■  "  1»'-S» foreign,,,, „„„„, 

"■«  it  will   l,e  sec,   ,|„,t  „;,,;|,.  ,„  , 
«»"„!  in  the  third  ,|„,,je.         '"  •    •'"  P"  «™'  "f  all  (!„•   eases 

Mortality Of  the   '''>q 

-  -erage  rate  of  n.o,;:,.t3n; ''  h!:^  I'  ''''  -"^'  -'-L  is 

"7  the  .nortality  has  ,..:  ^^  ::!  i'^^  "''  ^!'^^  -,d-hath  treat- 
'"d  conditions  inflnencin.  the  no.;  ^''.Vr''""'  -•'•-mstances 
'nsuleration  of  the  fatal  clses  ^   "''^  ''^  ^'^'^''^  ^^^th  i„  the 


"Annual  Report  of  the  ileiilM,  n 

"  iietutli  Department.  1892 


'I 


i. 


I   S; 


i 


William  Osier. 


[2 


Season. — Typhoid  is  essentially  an  autumnal  fever,  and  more  than 
one-half  of  the  admissions  were  in  August,  September  and  October. 
The  admissions  in  each  month  were  as  follows  : 

January  9,  February  6,  March  3,  April  5,  May  8,  June  9,  July  22, 
August  40,  September  38,  October  40,  November  34,  December  1(5. 

The  average  duration  of  stay  in  hospital  for  the  229  eases  was 
28.1  days.  I'he  majority  of  the  j)atients  are  persons  without 
regular  homes,  and  their  stay  is  sometimes  unusually  protracted;  i 
convalescent  from  typhoid  fever  is  allowed  to  remain  until  he  feels 
well  enough  to  go  out  and  work. 

The  distribution  of  the  eases  in  the  city  will  bo  dealt  with  in  a 
special  section  (VIII).  Only  one  case  originated  in  the  lio.spiial. 
A  nurse,  Miss  R.  (Hos.  No.  3729),  had  been  on  night  duty  from 
August  1st  in  ward  F,  in  which  was  a  large  number  of  cases  ol' 
typhoid  fever,  and  she  superintended  the  giving  of  from  seven  to 
eight  baths  every  night.  Prior  to  August  23rd,  when  she  went  off 
duty,  she  had  been  for  two  weeks  "  out  of  sorts  "  with  oot;asioiial 
headache  and  felt  very  tired  and  weak.  There  was  nothing  whatever 
in  the  history  to  indicate  that  she  had  taken  the  disease  outside,  and 
so  far  as  we  knew  she  had  not  been  exposed  except  in  her  daty. 

Another  nurse  had  typhoid  fever,  but  just  previous  to  the  attack 
she  had  been  outside  nursing  a  brother  with  the  disease. 

A  doubtful  case  was  that  of  Sallie  R.  (Hos.  No.  4716),  who  \-i^ 
admitted  F'^bruary  16th,  1892,  with  a  choreic  affection  and  spasms. 
From  February  16th  to  March  1st,  13  days,  she  had  a  normal  tem- 
perature ;  then  from  March  1st  to  7th  there  was  a  gradual  rii-e  each 
day  (with  the  exception  of  the  5th),  the  temperature  registering  a  little 
higher  than  the  last.  She  gradiuilly  developed  a  typical  attack  oi 
typhoid  fever.  She  was  a  resident  of  Hojjkins,  Accomack  County, 
Va.,  but  a  week  before  her  admission  had  been  staying  at  Barro 
Street,  in  a  house,  however,  in  whicli  there  was  no  typhoid  fever,  hi 
the  next  bed  to  her  was  u  patient  with  ty])hoid  fever,  but  it  is  quite 
possible,  and  indeed  probable,  that  she  received  the  infection  outside. 
as  the  fever  developed  within  the  limits  of  the  period  of  incuhation. 


r  f*= 


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JI— TREATMENT  OF  tvdw^ 

JF  TYPHOID  FEVER 

BvW.LUAMoSLER.M.a. 

{a)  Nursinq  and  Dht      o- 

™«J  and  fod,  and  Zi  1,  ™   L  "r.''"  ""= '""'»'  -  « 
...«l>a  ed  by  appropriate  renfedTe"    TT"'."'  '''™W  "'"y  »"se  are 

'-*  .f  best  expressed  in  the  te™  ,." '™f  ""=  """«■•-='  '"  "a"  - 
■»«li».ne  snnply  because  the  „aZt  I       .  ""P^^oy."  givin.  "o 

rfa^td^^™'-^-  ''''^  X'^atrj  '■"'"  ^"'-«"*° 

tares,  as  Sydenham  said  of  FT;.  ^  decisiou.     Hp  orJ.r^ 

™;;*-oeroi„.,  <.fontrt;ed!t   :?-•  "  "^  '"PPon  of  en^^:' 

A  Jarge  proportion  Of  all  cases     7^ 
any  and  all  for„,s  of  treatnae,  t  ;:  ,    ""'' ''°*  ^*  ^^ast-recover  under 
-d  regulated  diet  upon  vvhTrCh     ''°  ^''"^^"*  ^^'^  g«od  nursznj 
care,  by  careful  feedL  .nTi  '^^V^^''^  ""'«^'  ^t^'^ss.     Bv  ;„d;      ^ 

a'Hl.fanyrel,anceean  be  placed  '!,"     ,     '"'^  ^""^^^^  ^^e  saved 
P-  oent  are  saved  by  hydxJ^trera.n'v''""'  ^"  ^-^^^"^  three  or  four 

Good  nursing  not  only  „,eaL  ^  /  ^""'^''''^  ^-^'^■J.u. 
«,h.st.  '"^  P--"Se  of  „„ses  to  pa«el" "st^dlt 


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MiJk  is  the  Staple  article  of  diof  of,.!  •  i  r- 
g'ven  in  the  twentv-fb„r  hou^   '     J!  ';:    ^"'  ^''^^  ^«  ^o-  pints  are 
"i<"t8  Of  an  ideal  fever  fo.d      Jf2,  .'      "''*'*"  **^'^  ^^'e  req„ire- 

"-^«1  with  e,,-.n,,,„,„  or  •  t  t^'ttLl  "  :'^  '''  ■■■^  «"PP'e- 
f  "V"«P-tion  of  the  .stools  sJnvHCt  ^  '''n  '''  ""  ^''^^  «'^«» 
-jested.  Water  is  .iven  free  v  -  n  t  "  """'  ''  '^"*  thoronghlv 
•''•'"'!  - --f'  of  it  as  he  ca^  '  ^t^ ^'''^'''  '^  — .ed  to 
-1  .n  fnll  doses  when  the  fbve^^  s  m  ^''\^""  ^^^^  -d.  bath, 
An  Klea  of  the  dietetic  and  r^i^Jf'  ''"^'  '''«  P"'«'  feeble 
■^tr<:ngth  in  ^  serious  ease  nnv  i  '"^««"'-t'«  used  to  s„p,,ort 

^^'!f^  of  the  diet  and  ZrZ^   :;  t^4  f""^  ^^^  ^ ^'  ^- 
rauldle  of  a  relapse.  ""^  -^  '"""•«  'n  a  case  in  the 

(6)   TA.  mUath  Treatmcnt.~-For  vears  1     J      ■ 
vogue  as  a  means  of  com ba tin,,  the  more    '    "      "    ''"'P^'  ^""^  ''^''»  "' 
ever.     Advocated  toward  the^  endTt  " ri'-'^''^^'^-^'^^^^ 
has  come  into  general  use  bv  the  .tron.     1         '""*"''•"  '••^'  C''''^''^  't 
many  and  of  the  l>hvsicians"of  1  r^        T'''  ""^  ^^'•='»'J  "'  «er- 
i".  l.ere  the  adn.lL.ble  re^J  Lt    ^1^  I  "t     '^  ^^  ^^'^^^''  'i^^" 
"'    ale,  who  practised  hvdrothera,      ,  t  ,    -1T"'  ^''^''''  ^'"'^''^ 
"'^b-ns  1798*:  "  B.,t  the  most  Sa   m    P"  'T'  "'^  -"-'yappar- 
Pe-at.u-e  of  the  body  is  l,v  the  „s    .^^  J'    '!"'  "?'"^'"'''"^'  *^'«  'em- 
■"^^rnally  or  applied  ext^-nally      Wh      ,  '  "''''''  "'^>^  ^^  ^-'<«n 

dem-e  cold  water  to  drink    i    sho     l''''""'"'*'^''^' "^'^'""^  disease 

abstracted  from  the  body  by  the  w.ter     h"  1    ^'   ''"""'''^^'   ''^"   ''^^^ 
-•-,  -  but  small,  and  except  in"  ;rwle     ',      --'  "''  ^''■'"'^■'  ^«- 
--ch,  ,t  produces  ,>erspiratio„,l  :^,  r''*-^-  '''  '"""--  -  the 
ihe  only  of>ectual  method  of  J     •  '"^  ''''>'  ^"^'^f?- 

k.  fc«t  ,0  any  *g,ee  we  ,,]„,«.     D      ,' ^     t"  ""."'"«  "'••  «>"  l«e„ 
**«.  modes  of  making  thiK  a„„  1  I        't™'°"""  """^  »'i°PW 

""BMn;  while  others  ,,rrfo,.,l™       ""•"'""■  »"<!  «'«i  replace 
W;.  ca«  „h.re  oold  ,Ja,e     Z    |"^  '""'  "''.''  »'''  'va.er.     We 

I" '™"' •«  too  mneh  ml„ce<l  t«7e     ,  '"""'<■•  ™  "I'H'h   our 

«"»g  1»».„«  „i,h„„t  i,,,,;  '  '      «  ■''-•™  ""«  of  bed  an<l  placnxl  i„  a 

-     »    y  ''"'  ^'"<^  '-■"ii'-se.    New  York,  1834. 


iil 


I 


y 


WiUia7n  Osier, 


[6 


will  be  neces.eary.  The  method  which  I  hiive  adopted  is  to  turn 
down  the  bedclothes  aiul  to  dash  from  a  pint  to  a  gallon  of  c^ild 
water  on  the  patient's  head,  face  and  body,  so  as  to  wet  both  the  lied 
and  body  linen  thoroughly.  It  is  better  that  he  should  lie  on  a  straw 
bed  when  this  is  done ;  it  is  not,  however,  essential.  If  his  bodv 
should  be  very  hot,  he  may  be  turned  upon  his  side  and  the  water 
dashed  upon  his  back. 

As  soon  as  his  linen  and  the  bedclothes  begin  to  dry,  and  ilic 
heat  in  the  head  and  breast  begins  to  return  to  the  surface,  (lie 
water  should  be  again  applied,  and  in  this  way  the  heat  may  be  Icent 
down  to  tiic  natural  standard,  or  rather  below,  on  the  surface,  so 
that  the  skin  may  feel  rather  cool  to  the  hand  of  a  healthy  person. 

It  is  not  very  material  what  the  temperature  of  the  water  is,  if  it 
is  below  blood-heat,  excepting  the  shock  given  by  its  first  contiut 
which  in  cases  where  there  is  much  stupor  or  coma  is  of  some  im- 
portance; in  general  the  effect  is  produced  chiefly  by  the  evapora- 
tion." 

During  the  first  year  of  the  hospital  work  the  cases  were  treated 
symptomatically,  but  the  remarkable  results  published  bv  llraiid 
and  by  the  physicians  of  the  Lyons  school  seemed  to  make  iinjxni- 
tive  the  adoption  of  hydrotherapy,  so  that  we  determined  to  give  it  a 
full  and  fair  trial.  Accordingly,  Dr.  Lafleur,  the  former  first  assis- 
tant, now  of  Montreal,  after  a  visit  to  the  wards  of  Dr.  J.  C.  Wilson 
at  the  German  Hospital,  Philadelphia,  began  the  practice,  which  lnr 
more  than  a  year  subsequently  received  his  personal  supervision. 

1.  Dctdih  of  the  method. — The  patient  receives  a  bath  of  from  W 
to  70°  every  third  hour  when  the  temperature,  taken  in  the  rt'ctuiii, 
registers  102.5°  or  over.  The  tem[)erature  of  the  bath  varies  some- 
what with  its  antipyretic  influence;  thus  when  the  fever  is  veiv 
slightly  reduced  by  the  bath  at  70°,  a  lower  temperature  is  employed. 
The  temperature  is  taken  every  two  hours  in  the  rectum,  and  if 
it  rises  above  the  i)oint  mentioned  the  bath  is  given.  The  length 
of  time  tlie  j)atient  remains  in  it  varies  somewhat,  but  unless 
otherwise  directed  the  bath  is  of  twenty  minutes  duration.  The  bath 
tub,  of  which  there  are  several  light  portable  forms,  is  whecledtothe 
side  of  the  bed,  around  which  a  ward-screen  is  placed.  In  all  instances 
the  patient  is  lifted  from  the  bed  into  the  bath.  There  is  an  arranL't- 
ment  for  the  support  of  the  back  of  the  patient,  either  a  comfortable 
padded  sloping  platform  or  a  properly  adapted  water-cushion.    The 


7] 


Treatmmt  of  Typhoid  Fever 


water  is  deep  enough  to  .over  entirely  M,o  chest      Tf  ..        u 
sary,  the  ,)atient  receives  a  snmll  ,„■ .  .-V     7    .  t''0"ght  neces- 

of-HK.  l<in,l.  rro  is  lifted  n  o  hi  r  "^^'"^  "''  ^  ''"^  ^^^ink 
'  '''''1«1  ..npkin  around  Z To^f  A  Ih""'  "''' ''  ^^'^"^'^  "^  -^'' 
i-  placed  upon  tho  head   .,nd  wiil".  "'"""^  ''"*  "'"  ■'-'c-water 

^<i.t  bathed  in  the  sanle'.  :   ;^"  Th:.:^'  n'"".  '""'  ^"''  '^^  -« 
"■-in.portant,  partioularlv  in  cses  w  M  r"'  '"  '^^  ''^'"'  ^''^ 

^'''"  ^'-^«  -'1   trunk  ar    "^".ulr^n' r^""  ^^■'""^"™«- 
liamlof  thonursoor   ulpit  is  ,  '     "''*'"'''  "'^^'^^   ^^''ff'   the 

0-  of  the  for^s  of  L^  ^  C:::"-'--'  '-'''  ■'  '^^'^  -  ^vit^ 
l-f""t  is  in  the  hath  the  bed  s  n  '  "\T"T  '"'•  ^^''"''^  ^^'^ 
-•■''-  sl'-t,  a  blanket,  an  ov  T  ",  '"  ""'•^'""  ^^'^^  a 
patient  is  lifted  out   Jd  i    '  .  *'"%""    "'*'  ''"^"  «heet.     The 

.lrie.l  at  once  and  t;     p  ^  ,!^/->  J-;-'  case  with  feeble  he.rt  i 

Patientistuckedcareft    y    ;;;  ,^7^^^      ^"  «^'-  instances   the 
an<l  covered  with   the  hi  nk  t  tfo  eh    '  'T  "^^  ^"  ^^"  "^'""tes 
l«tio"t  is  given  a  hot  .    i        „     '^^^^^  ^'f  "  ^^'^^'-'^'^'^^  ^ricd.     The 
l-.r  after  the  i>ath  the  t      L"         '  T  f'^"'  ""''  ""^^^-     H'^'f  -' 
.-I  of  three  hours  the  tem  "  ;      ""  "/'  "^"^"'"^-    ^^'"*  ^^'' 

is  repeated.     During  thoZth  ttV    iv"'       "''  ^"^-'^^  *^^^  b'"^*'' 
'■""y  watched.     Tho^g     ,ttst  1  •"  "'  '^'  ''''''"'  '«  --'- 

:.blc,  within  five  or  siv  .i  „t "  t  T  "  ""'"'  ^'  '^'^'^  "^'^ee- 
in.'  cold  and  beconK^'ler  Tn  '"^"."^"'^-^''>'--I>Iainsof  feel- 
I'eginsand  the  patient's  teeth"  chatter"''"  the''  T'^'  ''''^'^^'-^ 
l)econ.e  a  little  blue.  Systematic  f!  f  I  ^''^''•^'"'t.es  and  fiice 
shivering  and  the  tencle.i^ -"o  c    .  "";^':  "^'"'^  '"^  -""^eract 

^■iinvatched,andthe;;;::t;;^;  'r\,th  '^  r'^"^^  ^'^  -- 

^'resigns  of  increasing  weakness.  ''  '      ""'  '^'''"  *f'^'"^' 

file  pi'ocediire  noon  vilnV-i,  n       ^  , 
.».nel,:  ,ho  carrying™:,         I    1"h>7; ''"''»'«• ''''Srea...,^ 

I«?in..ins  of  the  diiase  bv  vl  ich  *?"■"■"'  '''■™'  "-  -">' 

««tox„.|„i„„.le...e,,  «,     L  '     T'"'"'  '""^''^-    On'vi" 

>•  *e  ™<1  of;  the  first  woeic  ■■"'""»<««■«  "ere  i„, „„,,  „3„„,|, 

''"P«.*  was  ctabiis    ,".';»">■  ''<«"»  'he  baths  before  the 


8 


Williniii   Osier. 


[>^ 


The  frequency  of  the  baths  dependfi  upon  the  severity  of  the  cis, 
Four  is  an  average  iiiunl.er  for  the  24  hours,  but  the  maximum  UMinh,r 
possible,  eight,  iiave  often  to  be  giveu.  The  arrangenjents  arc  s,,,!, 
that  they  are  given  in  iii(.  night  as  well  as  in  the  dav.  The  Innrp.t 
Dumber  of  baths  given  an  individual  case  was  147  ;  live  eases  r.c.  iv(,,i 
more  than  100  baths.  Though  followed  as  a  matter  of  ronti-,, 
there  have  i)een  siuec  we  began  the  treatment  (Ive  cases  in  wliirh 
the  patient  was  admitted  in  such  a  state  that  it  was  not  tli.ni.hi 
advisable  to  bathe  him  ;  while  in  eight  eases  the  extr<>me  debiliir,,, 
the  patient  madr  us  abandon,  sometimes  for  a  time  onlv,  the  tiiat- 

llHIlt. 

Brand  urges  that  all  cases  should  Iw  bathed,  that  every  ease  „t' 
typhoid  fever,  whether  grave  or  moderate,  should   be  treated  by  tlic 
eold  bath.     This  we  have  not  considered  n(!ees.sary,  and  of  the'  Htii 
eases  admitKd  since  the  beginning  of  the  treatment  there  wen.   '•' 
winch  did  not  receive  any  baths,-nearly  all,  except  those  above  men- 
tioned, mild  cases  in  which  they  did  not  seem  indicat(-(l.    In  bin  .,„e 
instance!  in  the  entire  series  did  a  patient  who  entered  with  i..w  tem- 
perature su!  -.(.lently  develop  serious  symptoms  with  high  fever  nnd 
great  prosi,  ■.!-.,>,    The  case  is  of  no  little  interest,  and  an  abstriu  i  „f 
It  will  be  f-?!!o,i  itmong  the  fata!  eases,  Xo.  22.     Wo  did   not  roallv 
appreciate  th.-n  he  had  typhoid  fever  during  the  first  week  in  i,o.'- 
j)ital.     The  i:  .aperature  chart  was  very  deceptive,  and  we  tiMm-lu 
that  It  might  be  an  anomalous  form  of  malaria,  but  rep(>ate(l  exami- 
nations  of  the  blood  were  negative.     After  the  enlargement  of  the 
sj)leen  and  the  appearance  of  a  few  rose-spots  rendered  certain  tiic 
diagnosis  of  tyi)hoid  fever,  the  temperature  did  not  ri.se  above  102^ 
until  th..  thirteenth  day  in  hospital.  The  baths  were  then  begun,  hm 
the  case  proved  to  be  one  of  unusual  severity.     lie  took  iii'lij]   11} 
baths.     Death  occurred  from  perforation  on  the  fiftv-lii>t  dav.  One 
could  not  but  regret  that  the  baths  had  not  been  started  at  tlie  outset. 
2.  Genrraf  resu/f,^  of  the  tmdment.— Without  enteriuij  upon  a  dis- 
cussion of  the  theory  of  the  action  of  the  eold  bath,  th,rn,ost  hupon- 
ant  effects  may  be  said  to  be  in  the  reduction  of  the  teDiperatiiro  and 
in  the  general  .stimulating  eifeet  upon  the  patient,  particularly  iipo,, 
the  nervous  sy.'^tem. 

Brand's  statement  that  by  the  cold  bath  it  is  possible  to  keej)  tlio 
patient  in  an  afebrile  condition  is  not  borne  out  by  our  experience, 
In  a  majority  of  cases  the  action  of  the  bath  is  prompt,  and  within 


'ity  of  the  caKc. 

xiiinuiniiinilHT 
iients  arc  such 

i'he  Inri^cvt 
e  cuscs  rcccivcil 
iter  of  roiitiMc, 
casoH  in  wlnVI, 
!is  not  tlioii-lit 
cine  (lcl)iliiy  ,)| 
)iily,  tlio  trciit- 

(ivcrv  case  of 
treated  l)_v  rln 
11(1  of  the  |!ii; 
tliore  were  :'•_' 
ISO  above  iiii'ii- 
(1.  fn  lull  (iiio 
witli  low  tfiii- 
liitrli  fev(  r  md 
an  abstnu!  nf 
lid   not  reallv 

week  in  ims- 
d   we  tlioiiglii 
peated  e.xanii- 
reinent  ol'  the 
'd  eertain  the 
V  above    102 
en  beijiin,  but 
)!<  in  all  111 
rst  (lav.   Oui 
at  the  outset. 
;  upon  a  (li>- 
niost  iiiipdi't- 
tperatiire  and 
iculai'ly  npnn 


to  keej)  tlic 
p  e.\])erieii(c. 
t,  and  uitliiii 


m 


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IMAGE  EVALUATION 
TEST  TARGET  (MT-S) 


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Photographic 

Sciences 
Corporation 


33  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


fV 


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No.  ''if''''     *  ''"'"'  '  yct^'^  ■ 


AdmiUed    ^f^  '/  '■  /'^■>      "HV//y/ 


Chart  II  showing  marked  action  of  the  baths. 


j 

{ 

■ 

dniiUed    ^'f^  '/''■  /''>      ^\\m^ 


JJ- 


:  <ts     •.■■■:     : 
■■♦••W--    •  ■■:•■♦  ■■■'.■    ' 


:  !»:;,>•   IV 


V 


e  baths. 


I ' 


lilO 
l«n     ;j 

17(1 

1«>(I 

150 
HO 

i;iO 

120 

no 
mo 

90 
811 
70 
60 

i 

50  I 

! 

40 


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'/f>      Tlwv/ 


ts 


.;    i.  ;.,  .;  ^, 

Mill 

180 

;.:..,,   :  .. 

i7li 

lull 

■•■•:•? 

150 

.......  ;  ...f          , 

HOJ 

:     .'■ 

i;iO 

■••■■  \-\  -;  ■• 

120 

nil 

„,.;...;. 

100 

::::i::.:. 

90 

;--i--;  •  ^ 

811 

.    .^...:  . 

70 

■■:-■'  : 

■■■■■■  ■;  • 

60  \ 

:■■■•■•  :  ■ 

.iO 

•ill 

•■■;■■•. 

--■ 

! 
1 

1 

1 

, 

30 

i 

1 

US 


It 


ts 


le 


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le 


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le 


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le 


No.   ''•("r. J{iA^.J{u, 


*^.   >^t.'?-.S5*«*<' 


Admitted     /«<^  ><. '^ /^/ >      Ward    t  .>. 


98 

»7 

96 
Temp 

Pulse 

Resp 

Stools 

Urine 
Dhv  of 


n 


iseaue 


.  ^  .;..   \.. 

♦■■  ■'■■  ■ 

«  ■     ■ 

» ■,■  ■■  ■ 

i. 

•'  ■  ■ 

^...,i... 

• '  -..;.. 

•  ...;..  . 

»    ■  V 

*■   ■•■ 

#....;. .. 

• 

♦    ■;.  ;..  ;... 

?••■■-■ 

«■■:■■•? 

■   ■•••r--'--f--f-^- ?■■■|•■^■  ■;■••■••   ^■••j••■:•■■^■•^•■  1  •■||   1...^....;...  j..  .|. ..,...:  .»....;  .|.  J  .  |.,  i... [...;.  .j.   j  ,;.,:..; 

T    ■■■     -f-p-:    ■   ■••■■;     ■v--;...i..  .J. . ....... ^....i....f.^..i..   .;.     .;....;..  .J..  .|..  -j  .,:...  .i..  ..;....,........,■...:..,  .|   .,|.,  ;,,  .j     .,;.      ;   .    |      .;      |      ;     | 

,..:  /:,.■, ,/  ,..:,,vi,»,  ,,>;^*;,^;.,,  ,i^,,i:,,r,,,t,».'^^^                    „j;»;„/,^,,;„,  .^r;,^.^;!^;  ,•;,i.;,w^.^:,«;,^:,,,;,«U 

"  '   ^ — '    ■*-"-^ — i.:i_i-.:.ii4:_^;--'"i---;--  ■•-...:..  -i.. i ..  :  ..  1 -..,;.  ...i..    •  ...i... .  ■      :            ; 

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i     1 

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10 

,'.  / 

80 


70 


60 


50 


40 


30 


Chart  I  showing  very  slight  action  of  baths. 


:*'it 


m 


i 


I    /t^  >  ^  /f.^       Wa/r^ 


j± 


■If    ■■:■ 


■*1 


r  ^f;- ■;■■■;■••  if:-! 

■*.•*■_•■     ■■■    •  *-■  ;»■•■  ■■       •  t  ■     •■ 


:  .'.W  lit:  im'ilr.  l*:'iijH:l*>^fU.l>/;iif  lu  '  'i 


UiijfiifU/:^'';^*:.?*.,'':,?*'^*!-^:  "■  '■ 


•;•  r  ;""ri 


Tui»r 

IHI) 
180 
170 
16U 
1.10 
140 
1»0 
1?0 

no 

100 
90 
80 
70 

on 

50 
40 
30 


hs. 


i'J 


Ward    C 'f 


II 

tit;; 

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IHll 
170 

..;....j. 

160 

150 
140 
KIO 

r.'o 

llll 

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101) 

n  ■ 

90 

..  . 

80 

'■ 

70 

v:;-'.; 

on 

"■U":".. 

50 

'»r'»:"^'f    ■«•" 

40 

>f.^>Ui(.  y    "■  ■' 

<•  ■•'■  -r     — s-    -  - 

30 

1  ^  i 

_4 (- 

,"    ' 

Trcatmmt  0/  T,,p/ioul  Ferer. 


I'^'"'^'"  '"»"•  "fter  the  patient  comes  out  of  the  Intl.  flw.  r,  .  1  . 
IHn.nre  i.s   lowered  from  one  to  three  ch^r  e        T  .     "' 

show   as   a    rule  a    crradn-il   ri«,     '",/    *^  ^  ^"'"  *"""*  •^'''"'^^ 

tcnperatnre    is   .In"       .     W  T      '  •'  '"'  ^'"^  ''"■  ^--h-"-iy 

it.L.riu.i,ht.^rtheriX  :;;:'rr 

-  s....  ti.e  fever  Kept  do.„  r.Lor.  tl-an'a^:  .  ":  ^^rt 

otlier  liaiid  there  are  nof  -i   fi.,,,  „,.         •         ■  •  .  "oiii.s.     vjn  tho 

in  -vl,id,  a.  ,1,.  e„d  „f,h,  „,„*•„,  ,„„      ,;„„:,      J''  '""■^  »7 

»,  .V,,,  lau.,-,  ,i,.,,,„i„  ,,i,,  „„,  „,„,„ia';i  t ,  i::i": ;;:'; 

IS  10  siy,  <l„l  not  ,.„|„„o  i,  f„r  „,„,,  tl,„,  (Vn,        i „■  '  """ 

T,,e „„„.,„,,„, „„,  1,,..::: ;,:;: ;:- :  ;•■  - ■'«.-. 

On  the  odicr  hand  there  arc  case?  in   vl,i,.l,  .1      i      ' 

"■■■>■ "f"".v,an,l  „n  overv  ^^i      :        ^ ''^  '»' ">° '■"' 

imni.al  ,)r  even  to  il.i"  „r  <)(!»  '  T„       1 1  ?         tei„|,erali.ro  to 

»■.,-. a,  »ee„  fron   „     Z^  o,     e'       u"  'T'''"""'-,'--'  "'«  «'-™ 

in  .1..  later  period,,  a.  i,,,:     tir';,..!     "-,:".';:""•'• '' '"  .""■'  »  '"' 

i"-  .1.0  Lath  bii ' :  ,,:  r,  i";"» .  ""■. .--  °f  - 

It  ".»>  in.le«l  bee„„,e  extreme  vain,  ,"  ""■'"""■''■ 

i.  |»r,ie„larl,    „„,i„,ble    in     as         I,' "  '"'  ",  ''T'^'  "'''''' 

<li.™tie  ,,nl»e.     After  the  ...  i         ■  ''""'"'    ""'    "''""''. 

sr«;T;::.;ta:rr;,,]:a:£i™^ 

«.i.a;e.theaha.,;,„nn,e„t„,.,!e';::t:;;,.:::;.i;:';:;;:»,: 


■i' 


I 


il^ 


hi 


10 


Williavi  Osier. 


Ill) 


earliest  i»erio(l.  Thirteen  patients  presented  marked  nervous  foiitiiiMs. 
but  this  is  !i  very  sniall  nuniher  in  the  whole  series.  Certainly  tin 
symptoms  to  wiiieh  the  term  "  typhoid  "  is  applied  are  not  nearly  -o 
frecpient  under  the  cold-bath  treatment.  Thus,  at  the  tinu>  of  writiiii: 
(October  20th)  there  are  tweuty-eitiht  eases  of  tjphoid  fever  in  the 
medical  wards,  not  one  of  which  has  or  has  had  delirium  or  trcmm'. 

On  the  respiratory  system  the  baths  exercise  no  special  intludiic, 
They  certainly  do  not  aggravate  the  preliminary  bronchitis,  aiul  ilc 
idea  that  they  are  liable  to  induce  pneumonia  or  pleurisy  is  entirely 
groundless. 

Patients  treated  with  the  cold  batii  appear  less  often  to  have  iln 
dry,  brown  tongue.  Gastric  irritation  is  not  sofreciuent.  niarrlmn 
and  tympanites  are  so  variable  symptoms  in  different  epidemics  tiiat 
it  is  diilieult  to  say  whether  they  are  specially  intlueneed  iiy  tin 
baths,  but  comparing  the  series  treated  with  and  without  the  Imtli,-, 
they  certainly  appear  to  have  a  good  effect.  There  were  seven  cases 
of  hemorrhage  in  the  bathed  cases  ;  only  one  in  the  thirty-three  ca-ts 
treated  symptomatically.  The  proportionately  large  number  of  ruses 
of  perforation  among  the  fatal  cases  was  probably  accidental  and 
had  nothing  to  do  witli  the  treatment. 

The  number  of  relapses  in  our  bath  scries,  9.2  per  cent,  contriists 
strikingly  with  the  entire  absence  in  the  small  number  (rented 
symptomatically.  The  incidence  of  rclai)Se  ranges  in  ditferent  places 
from  2  or  3  per  cent  to  9  or  10  per  cent,  and  it  does  not  stem 
right  to  attribute  any  prejudicial  influence  to  the  baths.  Coniplicu- 
tions  with  the  bath  treatment  are  rare,  and  the  only  unpleasant  eiit 
was  the  skin-boils,  which  certainly  occurred  in  a  greater  ntitnliei'  o; 
cases  than  in  any  series  treated  l)y  me  in  other  hospitals. 

The  cold-bath  method  carried  out  in  all  its  details  is  exceediiiiily 
onerous,  j)articularly  if  thert;  is  a  large  number  of  cases  in  the 
hospital  at  the  same  time.  It  is,  moreover,  to  a  very  consiileraide 
majority  of  all  the  patients  excessively  disagreeable,  and  at  least  nine 
out  of  ten  of  our  patients  have  comjjlained  bitterly  of  it.  So  liarsli 
does  it  often  seem  that  I  would  not  sutler  it  in  my  wards  tor  u  day  did 
I  not  feel  sure  that  under  its  systematic  employment  the  deatli-rntf 
in  the  disease  was  definitely  lowered.  Results  such  as  pul)lishe(l  by 
Brand,  in  cases  treated  in  garrisons  and  in  private  practice,  cainidt 
be  expected  and  are  not  obtained  in  ordinary  hospital  work.  The 
mortality  in  the  Red  Cross  Iiosj)ital  at  Lyons,  as  given  l)y  Tiipiir 


llj 


Trenlmeiit  of  Typhni,!  Fmv. 


n 


:i?i(l   Boiivorot,  irivps  n    .w... 

p.fo,l  „f  „,n,  ;^e.ar,s,  an,l  prior  t„  tl.^f  .?;,,"  ^  '  ''"''  "'"^  '"  «'"e 

Tl-  3.3  oa«e.s  treated  sv  n,,t,.    „       „'   T       \  "'  ''  '•'"•  '^•"^■ 
'"•^I'ital  work  ha<]  a  ...orialilv  .^^^  .; t:'  '^  ''''  ^"^'^  "'"  ^'- 

H<n'  <.f  unusual  sovrritv  •  one  iv..«  .  .  '"'  ''''"''"'  '"'"ever, 

nq.l.riti,s  one  was  a.hnitt'e,  "    r  "'"."^^.^'^  -'^'>  -•-^e  l.e„,orrha,i 

i-lciouble  pnounK,nia;t';!.::'S''7  "'■;''■  ^'"^'^  "••'^  ^''^ 
hmerrliajr,.  fron,  the  i,owe)s      Th  *,     '"''"'•"■''t''*".  »"<!  one  of 

"'•the  cold-bath  treatn.ent  ha"s  bvvu  ZT7T  """'  ''""  '""••"'"<^^tin„ 
Of'course  the  number  fn„  .    i  •  ^     '^  percent. 

-'••-«.butZ;  ,:;:,;: j;;"^- 

-  low  for  general  bos,  U        Im    "  '"^'"''^  ^"^'^  '^  -tainly 
-"orfalify  in  typhoid  fever  r  1,    1  V  ^  """"''■•^■'  '^«  ^^•'■'•"Se 

of  30  or  40  ca^es  nmy  be  reat"  d  '  "  '"  '"^  ''  ^'''  -'"'•  ^^rf.s 
0"  one  occasion  theL  l^^  ^l^rTV'-'r"  ^^ '^^"^''^  ^'- 
"»  another  occasion  37;  and  6uZT^  /'  ''"''""'  "  ''^"^^  ="'d 
™o  death.     Of  the  14  fa!  *'"'"''■''  ^onsceutivelv  with  only 

-fnent,  one  cal   '  .';|:ii:r:  ^T  *''^  r^'--'  ^^'  ^i.<'  l>a th 

'M  on  the  twenty-third  dav  h-Lv!  ''"' n  '"""""'  '"^"^«'^'^'  ''>"J 
«'n.itted  in  the  third  week  t  I^'  'Z'  !''  f '  '"^^''■^-  ''^'-ee  were 
""  tl.o  seventh,  one  on  th.  JZhTu  ""  ^''^'  ^'■^^''  ^'•■'-^•'  ^"o 
''^^•-;u.  on  the  twel.h.  o:;:?;';l;;:;:;--'!-'--he  tenth 
possible  to  say  how  Ion-,  he  h-.d  bo.,     11     ,'  "  '""'  '*  "'««  "»- 

condition  was  thought  tVl  e      'u!  "      '  ""^■•'''^'-^"^'^1  -ses  t],e 

'^e,.ost-.orten.  shewed  H\r::';Za'^l-''-^^^  «'^'  ^^n,  but 


\r 


C^  X  t-/'_ 


in._A  STUDY  ov  rriK  fatat.  casks. 


Bv  WILLIAM   OSLER,   M .  D. 


* 


i. 


! 


Manv  <'irciimHtaiu!eH  iuHiicnco  the  deiith-riitc  in  t\  plioid  li'\(  r.  (,| 
wliioli  the  most  iinporttint  are  the  inherited  dis])()siti()ii,  tlic  miikiiihi 
ami  ehariU'ter  of"  tlie  poison,  the  time  at  wideh  tlie  patient  kjimo 
under  Hkilled  eare,  and  the  mode  ol'treatnii  nt. 

Tiie  variation  in  wymptoms,  so  strikinu;  in  the  infections  disc.i-.(., 
no  one  case  resemblin<j;  another  in  all  resjx'etH — what  is  it  !nit  the 
expression  of  the  individual  disposition,  the  jtersonal  eciuation  '  All 
are  not  e({iially  susceptible;  some  are  immime,  others  seem  to  iiiivc 
an  absence  of  what  have  been  termed  the  protective  (i/c.vliis.  AIiikisi 
the  only  definite  fact,  the  only  certain  point,  illnstratin<>-  indivi(lii;il 
disposition  is  the  varyinfj;  ineidenee  of  typhoid  i'ever  witli  ai:e.  'flii' 
conditions  favoring  infection  increase  with  eiich  (luiniiiienniiil  pcridil 
from  the  third  to  the  sixth.  Not  the  tender  blade,  not  the  bud.  lim 
tile  full  flower  of  early  womanhood  and  manhood  falls  vietiin  to  tlii- 
seonrjje.  The  eases  are  not  only  more  fre(pient  between  the  llth 
and  25th  years,  but  the  death-rate  at  this  period  is  the  highest.  Oi 
th<'  22  fatal  cases  in  our  series,  11  were  under  twenty-live  yens 
of  iige. 

Ex])erimental  evidence  has  abundantly  demonstriited  that  tin 
symptoms  vary  with  the  dose  of  a  poison,  and  while  anaiooy  woiiM 
lead  us  to  infer  the  same  in  the  spontaneous  infeetions,  we  know 
nothint!;  of  the  circum.stances  influencing  the  dosage  in  typhoid  icver; 
not  even  if  the  variations  dejiend  on  the  amount  of  infective  iinitLiiil 
or  on  differences,  at  diflercnt  times  and  in  different  jilaces,  in  the 
intensity  of  the  virus.  The  severity  and  duration  of  the  symptoiib, 
and  the  termination,  whether  in  deatli  or  recovery,  are  iiiiliionad 
jirimarily,  in  a  larsic  majority  of  all  oases,  by  these  two  factors,  vi/„ 
disposition,  constitution,  soil,  or  whatever  we  may  term  it;  and  the 
virus,  possibly  by  its  relative  virulen<'e,  possibly  by  its  dosage. 
Fortunately,  spontaneous  recovery  follows  in  a  majority  of  tlic  eiists 
in  the  .self-limited  infections,  .such  as  typhoid,  typhus,  smallpox,  otc. 
The  term  mlj-lhiut,'(l  implies  that  the  duration  is  fixed— fixed,  we 


I'M 


^1  S'fHflif  nf  fhr   Fatnl  <  •„.,,«. 


(l.rn.crly  tho.ml.t,  l,y  an  exhaustion  ..f  the  .„il  „„  „, 

•H'nisniorc  likolv,  I,v  tl„.  „,,„Im..I     '     ,   ".'"  "'*' K'Tnis;  now,  as  it 
inhil.it,contn,lan:i,iJ,^!       :;;:'';;■••"  'f  7'--- 
.i«s.H.-Htute  unalo,aM.s  t<,  that  en?,  .";.?;''''   ""'"'•"■""  "'" '' 

Tiic  niortalitv  is  inlliiciic;.,!  „r„..ti,.  i     .1 
-.under  tn:atnn.n,'^';:r'rr^^^ 

t"  m.;.n  so  n.nch  in  f;.v.r  .a.,.,  th.  I.  tt,    tl      I      ^  '""''  ^■•""« 

ii,i,...f ,ho ./. ..//.,,./.,. .. . :; ,  i ""  *'""''""■•• '"  •»'«  1-1-K-i 

latorv  oases,  which  ftke   o         ;    i         '•"T"'^'^'  t"^"""""''-  A,„l,„- 
L'>  in  the  thinl,  S  i„  the  f„„rth    '>  in  'i  .        •  '"  ''"  '•'*'••"•'' 

■•Hruasin,.o;sihie  ^. ";..;' '';'!;''''' '  'v'"  ^"^'''"'"' '» 

ill-ss  hefij  entering  t/^  u  Xr    TUU    "  "  ^^^  ''""'""  "'"  *''« 
aeaths  in  patients  i„  The  fir  d  'fi  o    '    "'""  ''  '''"""••" ^"-•'  "''  ^•••^> 

^'^'--i-'-iHinitei;::t  ti:  :!:^;:•:;"  ^^•'''^'' •-- ^'"1- 

l"-il'n.,  the  .h.ath-r-.t  ''  ";' '""■'^'"  "''""''»  '"'•  '•«'«•- 

'7^;^-e-,::l^:;rtot;::i':^:;;:^ 

Nidiral  ward  tile  avei-i»r,..f.,(r.>r  '  ^M'"<>i(l.     Jn   the  men's 

'--."  with  tMo  onleriies.      In  e       .t        e^n  "  ''  ^'"  ^'^'^ 

fetion,rej,n.laritv.nKl  svst..  /    V  ''"■'•"'^'  '"'*  ^'^'"'v 

--i.;....fi.«;i::ii-^;i:;;;j':::i;;:::!::«.;;;';' "".. 


I  I 


I 


I 


14 


Willidiii    Osier. 


[1 


(2)  To  intercurrent  affections,  usuiilly  caused  by  an  invasion  oftii  • 
weakened  organism  by  other  parasites,  pneumococci,  strepttK'ncci, 
etc.;  and, 

(3)  To  accidents  of  the  lesion — erosion  of  a  large  bl'>od-vessol,  or 
perforation  of  an  ulcer. 

Analyzing  the  22  deaths  according  to  this  division,  there  cai'ic  in 
tiie  first  8  cases,  in  the  second  4  cases,  and  in  the  third  10  case^. 

I. — Death  bv  Pkooressive  Asthenia. 

No  case  in  the  list  died,  so  far  as  one  can  judge,  directly  from  tlic 
effects  of  the  fever,  that  is,  from  hyperpyrexia.  The  highest  tenipir- 
ature  recorded  among  the  fatal  cases  was  107°.  Nor  was  there  an 
instance  of  death  from  early  toxieraia,  by  which  is  meant  the  rapid 
overpowering  of  the  system,  and  a  fatal  result  within  the  lirsr 
week.  Such  cases  are  extremely  rare.  More  commonly  the  toxaniia 
is  slow  and  i)rogressive,  catising  a  gradual  failure  and  exhaustion  dl 
the  strength  of  the  i)atient,  usually  but  not  always  with  coma  and 
delirium.  Of  the  8  instances  here  given  6  died  of  the  progressivt 
toxicmia  due  to  the  disease  itself.  One  of  these  was  a  case  of  re  lapse. 
and  of  the  others,  1  was  admitted  on  the  sixth  day,  3  in  the  second 
week,  and  1  after  three  and  a-half  weeks'  illness.  As  a  rule  there  ii; 
marked  involvement  of  the  nervous  system  with  delirium,  coma  and 
tremor.  In  only  one  instance.  Case  III,  did  the  patient  retain  con- 
seiousness  to  the  end.  The  temperature  is  usually  high,  tlie  rani:*' 
from  103°- 105°.  Sometimes,  uc  in  Case  III,  which  was  vcrv  pm- 
tracted,  the  temperature  may  towards  the  end  sink  and  be  luinnal  dr 
even  subnormal.  The  pulse  is  always  rapid  and  feeble;  thus  tlie 
range  in  the  six  cases  was  usually  above  120,  and  in  every  instancr 
rose  above  140.  The  average  duration  in  hospital  of  these  case- 
was  a  little  more  than  12  days.  Four  of  these  six  patients  were 
bathed.  Iluxham's*  description  of  this  mode  of  death  is  particu- 
larly graphic:  "  Now  Nature  sinks  apace,  the  extremities  grow  co!d, 
the  nails  pale  or  livid,  the  pulse  may  be  said  to  tremble  and  flutter 
rather  than  to  beat,  the  vibrations  being  so  exceeding  weak  and 
quick  that  they  can  scarce  be  distinguished,  though  sometimes  tlioy 
creep  on  surprisingly  slow,  and  very  frequently  intermit.  Tiie  sick 
become  quite  insensible  and  stupid,  scarce  aflf'ected  with  the  loudest 

*Aii  Essaj  oil  Fevers,    Second  edition,  1750,  page  78. 


]ol 


A  Study  nf  the  Fatal  Oa^es. 


15 

noise  or  the  strontroff  Mcrhi    i^i        i 

I"'"'"'>'"h1  coma,  and  thnt  delirium  now  ends  i„  ,i 

blnod-vcssd.or      ■      ='"'1  tears  run  off  involuntariiv'.lnr'™''^  '''''*•     '^^'''  «t"<'l^  "rine 

as  the  vast  tremblings  and  t   iL'm     'T";'"''  "  '^''^^^-^'  ^'i««"I"ti"", 

"'■  H'e.     In  one  or  other  of  thj  ^ ;';  ,re  t'h"  -"l'"  '''  ^'^  ''''"''' 
havinf.  languished  on  for  fi>urte,.r      t      *^^  «'^'^^  ^'''''•'^l  "ff,  after 

--■times  for  mud.  lon'er ''  "'^^'"'  "'^  *"^"^^-  <'-•-' "'O'. 
The  eases  with  progressive  asthenia  are  as  follows: 
Case  III.      Admistiion  at  end  of  third  wfel-      n      * 

ba™  and  .he  had  at  Li  ,1  "  "*'  •""■  '""<»'  '"""-l""" 

:«l".i"«l  ,ho  >vas  i„  a  ver  .  ZZ^T  ";"•""'"""  "  ''">  ■     "'"«" 

-  »o,dio,.„,ic.a„,;:;:,:tM,r  .'n''  *"""?*""  '»=°' 

.'"■  ««I.  and  ,.„,„,  ,he  .o,.,„f;:     "  ^/r  "^  ^JH- a„„„. 

ttilarijod,  there  were  no  spots  ^een      Tl  u'        ^^'^  ^P't'eii    was 

i"'^ifai  the  temperature^l:  d  pr^^lt"?  f  ^^^^  ^^'^  "' 
"luch  sometimes  as  /i°  or  4°  l.on.        ?   •  '"'•'  ^''"•'at><>"s,  as 

1-ture.  On  August  h  anr;h"tl  rt'"""''"^  •"'"'  ^^'^'"'"^^  ^-'- 
i-^"-'"^'  onee  dropped  to  ^ll^  /^^^r  J^  ---^^i'. 
I".t  conscious.  On  the  10th,  Hth  and  19.,,  ,h  t  7  "I'^^l'^tie, 
103°  and  104°,  and  on  the  l^th  and    Lh  'T  '^'"^•^  ^'^^"■^■^" 

'h-o"  the  morning  of  the  13th    I  e  """"''  ^'"  ^^  *'«'"•«' 

^"  «  -  "'■  -as  norntu        "rem  i        f  ?"^^*"^«  g'--'"='llv  fell,  and 

I'-s,  then  p-aduallvros     a    rr,;;T  T  T'  ''■''  '''  '' 
rose  to  103.5°.  "  ^'"'^  ^^"''  ^'""  <'•'>•  of  her  death, 

The  irregular  and  low  temner-iturn  ;,   ,\  ■ 
^'as  associated  with  the  mo     Cf      ,         '"  '"''  '"^^'"''^^  ^''«  «'««" 
and  diarrhu-a.  '  '"^"^'^""'^  ^'•^^'^«'"''^'  '•'•^Pid,  feeble  pulse, 

There  was  no  autopsv. 

-ASK   VIII.      Admission  771  second  , re,'/       n-      i 
"■7--  l>ro,res.i.e  asthenia,  deatC^^Jl!;,^^ '     ''""''"'"'  '''''■'"'"  -'' 

<i.us  duration;  pains 


i  I' : 


16 


Williaiii   Osier. 


It; 


J,   t 


in  the  head  and  back  and  severe  diarrh(ea,  ten  and  fifteen  stools;  in 
twenty-four  hours.  On  admission  the  temperature  was  103°  ;  \m]>v 
108.  Throujrhout  the  first  and  second  weclvS  in  liospital  the  case  w.is 
regarded  as  one  of  ordinary  severity  ;  the  ])ulse  was  never  ver)  hijih, 
not  above  98,  the  temperature  between  102°  and  104°.  On  sevdH 
occasions  he  had  very  profuse  perspirations.  'Die  nnnd  was  eliur. 
The  diarrh<i'a,  which  had  been  troublesome  at  first,  was  chcckcil. 
About  the  bet!;inning  of  the  fourth  week  of  the  illness  tlie  symptoms 
became  aggravated;  the  pulse  became  more  rapid  and  feeble,  tlu 
delirium  was  marked,  and  he  had  very  i)r(mounced  muscular  trcnioi'. 
It  was  not  until  the  third  day  before  death,  iiowever,  that  the  pulse 
rose  above  100.  The  heart  sounds  were  clear  and  there  were  no 
comjilications.  On  the  15th  the  tongue  bwame  dry  and  brown,  tlu 
pulse  feebler,  and  the  heart  sounds  were  muffled  and  very  feeble  at 
the  apex.  Througliout  the  IGth,  17th  and  18th  the  temperature  was 
between  103°  and  104°  ;  he  was  delirious,  and  he  sank  and  died  nn 
the  evening  of  the  18th. 

Autoptit/.     Anatomical  diagnosis:   Typhovi  ulcem  in  ercry  Mage  nj 
development  in  the  ileum. 

The  ileum  showed  extensive  ulceration,  most  marked  near  tin 
valve.  Higher  in  the  bowel  the  patches  were  covered  with  l)ro\viii>h 
necrotic  sloughs.  Tlie  mucous  membrane  of  the  large  intestine  was 
extensively  congested.  The  spleen  was  much  enlarged.  The  heart 
muscle  was  pale  and  soft,  but  on  microscopical  examination  did  not 
show  fatty  degeneration. 

Tn  this  case  the  patient  had  been  doing  well,  had  had  only  niodir- 
ate  fever,  the  pulse  was  not  high,  and  of  fair  volume,  and  it  \v:is  not 
until  within  four  or  Hve  days  of  the  fatal  issue  that  the  symptdiiis 
became  in  any  way  alarming.  There  was  nothing  in  the  anatomical 
condition  to  account  for  the  sudden  development  of  these  more 
serious  symptoms. 


Cask  X.  Adnmxion  late,  prolxibty  in  third  ireek.  Hif/h  ferer,iii(ti- 
oi'ism,  diarrha'ii,  r/r(idual  e.vhauniion ,  death,  (tutopsy. 

Joseph  J).,  aged  43,  admitted  August  21st,  1890  (IIos.  No.  lGS7i. 
He  is  a  German,  has  been  in  this  country  eight  years,  and  states  that 
with  the  exception  of  "abdonunal  typhus"  (which  expression  he 
used  himself)  six  years  ago,  when  he  was  ill  ibr  live  weeks,  lias 
always  enjoyed  good  health.      In  .luly  he  had  what  he  called  a  sun- 


17] 


-'   f^My  of  the  Fatal  Case.,. 


in  etrry  >ttiiijc  nf 


.  rol-e        ^  ^"^ 

--■-al  cough.  He  was  s.'i  ,:,':'  '"""'"'  '""''  '""  ''^''^  ''='^ 
'"•s  tomperuhu-o  was  101.4°,  and  ,.'"""'•' ^''-'"^^  ^^'''  -''''» 
l-I'i;^.I-  On  adnn-.s,sion  n/in  "  i  l."""  •■'••'^"'  ^"  -"-  -to  H,e 
120,  dicrotic;  first  sound  of  the  I  e-n-  /•/T"''''""''"'''  ^^^'^^  P"l^e 
f  ,-Pox;  abdon.n  f„„  «„„  a  llttl"  .d  ^•^f■'■''''^  -""  -^"-'  "t 
dclined  rose  spot.s  ;  spleen  not  r.-iln-hlo  '  '"''''""  ""»^'  "'^'l 

--'-'-•^t  drv.  Patient  was  ,  d  ,'  ,;  "•'^";"  ^"^'^^"^^  "  '--T  ^t, 
«-t  two  days  he  seen.ed  prett  o  .  .^m^  "'Z  '^^"""^-^-  For  the 
--tnntly  to  ri.sc  to  105°  but  he^,^  '''''  '"'  temperature  tended 
he  had  a  good  deal  of  tremj      t^'  •    "'^''  "■^"-     ^^"  ^'•^"  26,h 

a^.ionu.n  was  distended;  rt;nn:r?'''"  ""^'"^'  ^•'^'^^-  T'^ 
='^  the  .seventh  rib  in  nippi;  ?•  ""  ^r"'''""  "'^^"''-^  "^^'-^h 
-1  h.vpochondriac  regions^  T t  ^  '  f  .'  ""'""'"  "'  '^^*  '^'- 
•l'«  "ipplo  line.     The  . splenic     Z  '  m'"'  "'  ''^'"'  ^"'"^««  i" 

«1-  was  not  palpable,  'ffe  ^^s  XX  ^""^  ^^  "-'«  ""*;  the 
n..e,  and  given  turj)entine  intennllv  O  .  o"'"'"'"  ^^■'■^''  ^"''Pen. 
^"^^-' -•*  ^i;f^ended,  not  tend^  ^^pres^^f  ^  f^'  theabdon.enlas 
general  condition  altogether  better  Vu  ,  ,  ^^^  """^  ''^o  marked, 
ti'e pulse  was  still  120?  a^he"8?h  ,  '''^'  '''  ^"'^^"^  "^  ^'-  -'^ 
132,  and  he  has  had  for  the  past  two  ]  '  "'"'  ''"'■''  '^'"^^  "•^^''^^^  P»l«e 
-^  thcevening  ho  failed  Srbt'"'  "-- ^.'arrhcea.  Through- 
"-  2f.th  and  died  in  the  evenin. "  '  "'  ""'^'  '^^'''^  ^"'^  ^veak  on 

The  urine,  on  admission,  was  dear  anr]        .  •      , 
"'^r^'  "ere  hyaline  and  gra.dar  caTts      S  7    ""'^'  ""  "'^'•■'"'■"'  but 
;  "«i  ••-"x.min  in  a  small  anu    nT  nd   '""^^""'T''^  '^^  -ine  con- 
^''««"'--"  --  "over  of  sue    :li  ^'-  S-nuIar  casts  persisted. 
Of  uneasiness.  '"""""*  ««  to  excite  special  attention 

This  i)atient  had  in  all   twenK-  «       i     , 
^'-d  very  well  and  did  not  2^^;^:!^^:'  "■^"'^'^  '^  — ^  to 
^«'o/«y    rOr.   Councilman)       !"    :'''"V^""''''""'^- 

/'««""o»m.  ^     ""P"^  ""'/*  «^A-//w,  i«c^>/e„^  broiicho- 

Peritoneum  smooth.     At  thp  I,.    •     • 
*'««<re«raPover'H  ,„tl  t,r''''f  "'V''"  il«n„,  .„•„„„„,  ,„ 

■«.« <!..' ixver's p.,.,:: :",::;"««,«' ■•  -■■»» c- „,„,„ 


'Jk' 


>   I : 


18 


WiUinm  Ot^ler. 


[18 


which  it  was  situated  was  raised  above  the  surrounding  parts,  and  the 
ulcer  was  irregular  with  eroded  edges.  In  only  three  of  the  ulccn, 
had  the  process  reached  the  muscular  coat.  Tiierewere  threci  sii|i(  i- 
ficial  erosions  in  the  sigmoid  ilcxnre. 

There  were  marked  (cdenui  and  congestion  of"  the  lungs  at  tin 
bases,  and  throughout  the  substance  were  several  patches  of  Ixkui- 
ning  bronclio-pneumonin.  The  spleen  weighed  137  gramiiics;  iIh 
kidneys  were  enlarged;  the  cortices  swollen.  In  both  there  wuc 
suuUl  nodides  about  2  mm.  in  diameter,  not  raised  above  the  surfaci', 
of  a  yellowish  color,  and  surrounded  by  a  zone  of  hypertemia.  The 
heart  muscle  was  of  a  brownish-red  <'olor ;  the  striiu  wer(>  well 
marked  ;  no  wide-spread  fatty  change.     The  valves  were  normal. 

(Jask  Xir.  Admission  in  relapse.  Dflirium,  Irif/h  fnrr,  sliijlil 
hcnwrrhdffcs,  dyspncra,  prof/ressire  cardiae  ircakiiess,  (Jentli,  aiiiojjsji. 

John  S.,  aged  34  (IIos.  No.  2983),  admitted  A])ril  2Gtli,  1891, 
Patient  was  a  bartender,  liad  always  enjoyed  good  health  since  child- 
hood. No  acute  illne.ss  until  last  autumn,  when  he  was  ill  i\n-  three 
weeks  with  fcvvr,  cough,  and  jiains  in  the  right  side  and  the  l)aek, 
He  got  better  and  remained  well  until  eight  weeks  ago,  when  lie  was 
taken  ill  suddenly  with  a  chill  and  fever.  He  felt  very  badly  and 
was  in  bed  for  six  weeks  and  a  half.  Was  delirious  at  times.  He 
had  no  ])ain,  not  even  headache.  About  five  weeks  after  the  onset 
he  began  to  sit  up.  lie  had  been  at  work  for  some  time  (lie  says 
three  weeks,  but  that  is  inccmsistent  with  the  former  statement),  when 
on  the  24th,  that  is  two  days  ago,  he  began  to  feel  badly  again  mid 
had  chilly  feelings.  On  the  2r)th  and  2(5th  he  had  vomiting,  with 
fever  and  a  little  nose-bleeding. 

The  patient  is  a  stout,  j)lethoric,  healthy-looking  man,  and  it  is 
diflicult  to  credit  the  stateme.it  which  he  makes  that  within  the  iia>t 
three  months  he  has  spent  at  least  six  and  a  half  weeks  in  bed  with  a 
prolonged  fever  in  which  he  was  delirious.  He  looks  now  a  very 
ill  man.  His  pulse  is  120,  tension  low,  but  not  dicrotic.  Tiie  tem- 
perature rose  in  the  evening  to  104°.  Abdomen  was  large,  pannie- 
uliis  thick,  skin  covered  with  u  very  co]»ious  and  typical  rose-red  rash. 
Kdge  of  the  spleen  distinctly  ])alpable.  The  heart  sounds  wen'  eleiir, 
the  first  appro'iches  the  second  in  character.  The  patient  was 
rational,  but  at  night  was  delirious.  For  the  first  week  in  Inispital 
the   tcmjjcrature  was  remarkably  continuous,  even  the  two-liourlv 


,^^*!Blfcta- 


10] 


^  Kliidy  oflhe  Fatal  (hse.'<. 


19 

temperature  sliowiiiir  very  littl,.  ,..,,.;..•       . 

rt  was  not  until  he  had     a        ^iT    ?""""   ''^°  "»'>   '^^''^ 
"'<-  --  "H,d,  variation  Tn  Z    e  7     """  "'"  '•'"•  ''''>«  ^'-t 

'1'^-  -<1  "f  tl.e  first  ue.,;;   ;,;',.        ••-'■-•     -^'-e  F>..Ise  towanls 

f>'--  '-«-r  states  that  the  ,     '   ""'    '""'T'^^-     ''^''^"  -«■  '.v 

case  previous!  V  treated  i'  ''''■"'  ''"^ '""""H''"  tl'""  in  an"v 
re<hiction  whatever.  Tlie  d.Ii  """•'  ^^"^  ''"*''•"  *''^''-«  "='•'<  m. 
-I-     Thepu,eJ';:.;       -;;;--'K;;;-,>otsean.eoutin 

ThennteofAray4thisasfoii;nv  uir  '  "''^  ^'"■-^'  '"^^  ^^"•^>""- 
tren.or  of  the  hands  ;  t„,„.,,,  is  'L-  •  .  'Tr''"  '  ^'''''^  ''^  '' '''»'« 
I"-'--  '>.Wed,48;  th;  i  ^  ri..::  7'  '^'T  I^''"''^' ^-•' ^  -- 
TlH.dvspn.a  was  n.arked;  th  7^  ^  Vf ' '"' "  ^"'•^- '^'•'•'"-•'' 
l"".aH  in  front,  and  there  vas  llJT.l  ;''"^^'"^'^^"'»''^  «ver  the 
-n.el.le,l  breathing  and  nun.:.  ^  J  ^^  ^J  '^''  '--«'  -^h 
ovtosis.     The  red  oorpuseles  u-er.  ..I  '"'  "'"  "'»  ''^"^■"- 

^^'"•t'-  '-tween  five  and  si     tl  u"  n     :"'  '^"  "'"''""^  J"""  -'-  '^e 
about  80  p, .  a.nt.     On  ih,.  ml      T  '■'"•';'"'^  ^''^  l>.^".ogioI,in  at 
■     bowels,  not  followed  bv  anv  fl  I   !  T   '  ''^^"^^'rhage  from  the 

-«te.l ;  heart  sounds  vn-v  f"  eb^      "    -"I-rature.     The  deliriun.  p,.- 
-^  '•<»"•  or  five  davs  1  e  b  t"  ''  ^"""-     ^''"'■■"g  *!>« 

rlu.a.'s,  none  of  large  an.ount     '"  ""'",^'-^-  -^<'  ■^-'-'  flight  he.nor- 
rai.i.l,  HO  to  1(50.    He^yn.  M     't         ^  '•?  ^^i^'^^neh  feeble  and 

theHth,whichwasab:^^    '?8^^;r''''^"^^^''^^- 
>H>t«i— ''Rashisfadin<..al  1         •      •         ^"^^^'^^•">   Ix'spital,  the 
'™p-y  extends  ab    .2  '^nZZ  "  -"-l-.blvdistende,!;  b^.e] 
-<i'-  44.     The.  dvspn;     •;    7  ''"^'^   "'"'••'^•"  '  l->-  1^^;  respi- 
--i.<"  head  eon.:^   :  f;::i  ■;::   :;^-rt;''-  t-  He 

amldu.d  on  the  15th.  '        '^'   «"»'^  gradually 

During  the  nineteen  d-iv  th*  ■ 
'"■•0  is  noted  as  below  102°"  in  theT'"'.""'/''  ''"''*'"'  ^^'"  ^""MHTa- 
""^  i"   «Pite  of  the  n.ot'     r   ;^^^^ 

^I'""^i"^-     He  had  in  all     7 1'^         'n    '^'*"'''"   '""""^  -"^ 
10-t^  in    the   great  n.ajorifv  of"    '  '  i  '^''"''^'•'"^"'•^  ^^as  above 

nearly  107°.  ^       '    "^   *'"'    ''^"^"'"'''^^  and    it   onee   reached 

The  special  interest  in  this  ease  was  fb,>    i  «   •. 
'"■»"'''-'«  to  a  previous  -.tf  c     •  .  ,    f /^'^"'^^  ■'Statement  whieh 
'"^  ^'''^'^ives,  there  appa.    u     "  n  b       I        T  ''''"'  '''  "— ^^  '>^ 


! -.1 


.1^1 


•i 


'^, 


■i^ 


20 


WUtidin    0.ile): 


[vO 


Aiihpaij.  Anatomical  diagnosis  :  Ti/ jilio id  fever  ;  ufcrrs  irHhcli'im 
bases,  ami  t/taiulu  in  a  starje  of  vmlulldry  infiltration  ;  fi'.sio)i.i  nf 
relapse;  catarrlial  pneumonia  of  loicer  hheti  of  hath  lunijs ;  artii,' 
mhirgement  of  the  spleen;  swellinc/ of  the  mesenteric  f/landt ;  old  tuhrr- 
cAilosis  of  the  lunc/s, 

T1k>  body  was  tiiat  of  a  larjj;<',  stronuly  built,  wcll-noiirisbcd  inmi ; 
occbyniosos    on   the  arms.     Pcritoneiini    sniootii.     Small    intestini! 
presented  in  tbc  upper  jjart  oi'tlic  jojununi,  100  cm.  from  thcstoniMcli, 
many  jjoints  of  extreme  congestion  in  tlio  valvuliv  ('onniventes.   'I'Im' 
upper  Peyer's  patches  in  the  jejunum  were  liyperaMiiic  and  swolKn, 
without  any  ulceration.      Lower   down    the   solitary   follicles   wire 
affected  as  well ;  some  of  the  Foyer's  patches  were  greatly  elevntcd 
above   the   surface   and    had  very  sharp  edges.     The  first  distimt 
ulcer  was  20  cm.  from  the  valve.    Tt  had  clean  edges,  and  a  bnse  on 
the  muscular  coat.     Close  to  the  valve  was  a  series  of  ulcers  with 
perfectly  clean  bases.     In  the  upper  portion  of  the  ileum  every  stiiuc 
of  change  in  the  glands  up  to  necrosis  was  present.     There  were  iid 
distinct  sloughs  in  any  portion  of  the  intestine ;  the  (mly  lesions  were 
medullary  infiltration  and  the  clean-cut  ulcers.     The  mucous  mem- 
brane of  the  vermiform  ai)pendix  was  swollen,  but  not   ulcerated. 
The  mucous  membrane  of  the  descending  colon  i)resented  patches  of 
old   pigmentation.     The  sjdeen   was  much  enlarged,  weighing  7o(l 
grammes.  Mesenteric  glands  were  all  greatly  enlarged  and  soft.  The 
liver  was  enlarged  and  substance  soft.     The  heart  muscle  was  p.ik', 
isoft,  flabby,  no  mottling  visible;  but  there  was  extensive  fatty  degen- 
eration in  the  form  of  very  fine  molecules.     The  lung  presented  at 
both   bases  scattered   areas  of  bronctho-pneumonia   :ind    a  few  nld 
caseous  and  tuberculous  nodules.     A  ])oint  of  very  great  interest  in 
this  case  was,  whether  we  could  judge  from  the  anatomical  lesions 
the  truth  of  the  statements  of  the  friends,  and  of  the  man  liimself, 
that  he  had  only  been  a  short  time  convalescent  from  a  protracKd 
fever  fiefore  the  onset  of  the  attack  in  which  he  died.  At  the  nieetini: 
of  the  Hospital  Medical  Society  at  which  the  s])ecimens  were  shown, 
Dr.  Councilman,  who  ])erformed  the  autopsy,  regarded  the  condition 
of  the  lymphatic  elements  of  the  intestine  as  rather  bearing  out  this 
view.     Extensive  clean-cut  ulceration  in  the  lower  part  represented, 
he  thought,  the  old  unhealed  ulcers,  whereas  above  they  were  in  :i 
condition  of  unusually  marked  fresh  hyperplasia.     T  took  the  view- 
that  the  lesions  present    might   have   been    produced   during  tliis 
attack,  which  had  lasted  for  exactly  three  weeks. 


21] 


A  fUndij  of  the  Fatal  Cases. 


21 

('ASK  XIV.      Ad,ms,>on   !n  thinl  ,neek       Great  ,hl  77 
ikUnnm,  death,  (nifop.v/  'Mnhty,  meteorisvi, 

giv.. »  «,y  .«a,M,o.,„,  „o,,„„      ,  ■ ,         ■  '"'7  "  •'■;"•■    «'"'  ™" 
hail  been  ill  |b,ir  ivrcli,      ah.  ,.  ',  .        ■""''  """'I  'I'"'  »li<> 

f..r  tlim.  ,vock,  al,e  l,a»  liecn  i„   «I   ""'7';"";"S.C.r  .,.,e  „oek,  and 

n.i'  patiuit  uns  «cll  lV,r„„,l   ,    ,■"""'.•'•'"'  """'  ™n..tiii!:. 
.■<|..-.»io..,  .cnpera,,,;"  l^Jjot  ,:;i,lZ'"''"''  '""'  "  '»>>.<lull 
Tongue  dean  at  the  base       \Vl. 

"i-S  --where  tonder^  ,4  tr^"^  T''"^^"^'  '""'  ^^'-l- 
One  or  two  s.nall  rose  spots  on  h;,/  'V""'"  "'^'•^  ""^  P«'j-1>'- 
ing  rose  to  nearly  10o°      Thr.  „.;,       i  em,,eratt.re  in  the  even- 

1-i  retention),  contained  .1^,  ^'i^dT"  ;f ''•  '' ^''^''^^^  (^  ^he 
first  week  in  hospital  the  tenn.ervt"  i^  -''  '"'"''•     ^'"'"'f?  '^' 

SlK.  refused  nourishn.en  t "o,  tl  T/  ''"';''  ""^^'"'"'^  ''^■ 
restless  and  even  atten.pted  '^  1  .  '^  T"  ^''^  "'''■^  --.^■ 
-•"'"'f  •     The  abdo„.en  wns    erv  t  n  '  "'^  ""^  '"^^  *'"»^'«  '!•"*« 

tl.c'  0th  she  was  so  feebh-  h  t \,  ^7""'^'"  ''"  ^''^'  ^^"^^'-o"  of 
1-1  in  ail  thirty-three.  O^t^l:  f '^  T^/T'"'  ^''^^  ^'^  '-<' 
(•(instantly  between  102°  and  104°     <i  temperature  Ic^i.t 

"■as  distended,  tense,  tv,„p.„,i  '  -m  ^  T  ''';'"^^'''-  '^^'  ''''^^J""^"> 
the  middle  and  u,,r  ;,  r  n  l^'es  ""  ■  '''  ^'■"  '''''''  ''"'"-«  ''n 
-cd  more  rational  and  ut  ut  J  tn  "i"^'-  ^"  ^''^'  "'^^''  ^^- 
t"  '..ulerstand  what  was  1  id  T W  ^"'  '";  ^"'"'''""''  ^^^"^^^ 
^li^ht  pressure  o„  the  abdomen  ^^  J"  "'''^r^  ^""'^"'^'^^  <- 
^i''l-  On  the  9th  the  note  i  s  "P,  "  ';'"  ''''''  '^'^y  ^-Pres- 
<Kv;sl,ewasverv,,uiet;  pulse  better  T-V'  ^""''^  <l=iy  yester- 
l--'l"'"«t  disapp  ared         ^  '•  T  f^^^''"-    '^^^' ^-Vn.panites 

i"^t  b.si.le  the    Lt  m Me  no    !  '""'^''^^''g^''  "^  ^he  ri,.ht  hand, 
-»-vJ-t  indurated  a  d'^nTn  "'"'"'  •'""*'   "'^'^  '^    -^^''-ed 
i»*of  the  tinker  and    ir,^"-:;''"^'^"''  ^^^""""^  ^"""^  ^J- 
-■"i"g  the  general  oo,^tt  c,?  t     ^>:h     /  •''  "''  ^^^^'^^^^     ^^is 
-•^-Irawn;  .he  pulse  is  feebl  "'  "."■^'''^^'  ^''^  ^«^«  i« 

"'0".^h  not  so  diSended  ■  s    t    v'.  T""'  ''  "^^^'^  ^^"'Panitio, 

'^^lor.     On  the  right     't"„ale^ '''"'•''   ''"^  ''  '''^    '''^'■"  v^-' 
--  2  c,u.   in   diame  ;      th    !"      "^  "'^ , ''  "''  ''''-''<  '^'-ated 

-^^•"     ^-^ent.nkandl;ri;a;;rr^^^-"^^'^^"- 


M! 


-'.-w^!*** 


\ 


22 


Willi  mil    fhler. 


[■>•! 


Autojm/.  Anatomical  diajinosis :  Typhoid  fever,  HwelUnr/  itu<l 
lU'oroniK  of  the  folliclcH  in  lioth  .viKtll  ami  lan/e  iii/eMivex,  rdtdrrliiil 
pneunutnid. 

Till'  areas  of  local  iiiHamiiiatiou  noted  in  the  history  were  evident 
post-mortem,  and  the  axillary  jjlands  on  the  rij^ht  side  \ver<'  soiuc- 
wliat  enlarf^ed.  'i'he  jHTitoncum  was  smooth.  Tiie  diaphratcm  mi 
the  ri^ht  side  was  at  tiic  third  space.  The  lar<ie  intestine  was  Lin  atly 
distended.  In  the  ileum  the  solitary  follicles  were  very  much  swolldi 
and  elevated.  About  a  metre  from  the  valve  there  were  some  simill 
points  of  idceration  and  superficial  necrosis  at  the  apices  of  tiic 
swellings.  The  n])permo.st  IVyer's  patches  were  swolUai;  near  tiic 
valve  they  were  necrotic  and  stained  yellow,  and  presented  lari;e 
yellow  fissured  sloughs.  The  vermiform  api)endix  was  swollen  ami 
showed  superficial  necrosis.  The  large  intestine  was  dilated,  and 
throughout  its  entire  course  were  numerous  small  ulceraticms.  Tiic 
follicles  were  swollen  and  the  ulcers  evidently  proceed  from  tlicni. 
The  mesenteric  glands  were  enlarged.  The  spleen  weighed  SM 
grammes.  Tiic  Ividneys  were  large,  somewhat  swollen,  and  niidn- 
seopieally  showed  fatty  degeneraticm.  The  lieart  was  small  ami 
flaccid,  and  the  muscle  showed  slight,  very  diffuse  fatty  degeneraiiuii. 
The  lungs  were  congested  at  the  bases,  and  along  the  posterior 
borders  of  the  lower  lobes  showed  a  few  scattered  areas  of  luKiihir 
pneumonia. 

Case  XVII.  Admission  in  second  week.  High  fever,  ejirnnr 
e.drdiac  debility,  delirium,  pro(/remive  ddhenia,  dedth,  (iidopsy. 

Charles  W.  S.,  aged  22,  cobn-ed  (Hos.  No.  hb-^O),  admitted  .bily 
Hth,  1892.  Patient  had  been  iiealtliy  and  strong  until  the  present 
illness,  which  began,  he  thinks,  about  four  weeks  ago  with  pains  in 
the  legs,  weakness  and  diarrlnea.  He  did  not  give  up  work  until 
six  days  ago,  and  went  to  bed  the  next  day.  He  had  been  sliiilitly 
delirious  and  liad  some  vomiting.  Jilood  was  negative,  no  leiicecy- 
to.sis.  The  day  before  his  admission  the  patient  was  visited  at  liis 
home  by  one  of  the  house-physicians,  and  found  in  bed,  uneoiiseioii.-, 
with  a  temj)erature  of  104.8°.  On  the  10th,  the  day  after  liis  adniis- 
sio-.i,  the  abstract  of  the  note  was  iis  follows :  "  Patient  is  a  well 
noi:."ishcd  man  ;  tongue  is  covered  with  a  thick,  yellowish  fur;  tein- 
peratux^e  rose  to  105.7°  through  the  uiglit  and  this  morning  was  104\ 
The  pulse  is  136,  low  tension.     The  abdomen  is  a  little  full,  tyni|m- 


'■^■'1  ^   ''^'"■<'/  of  ihv  Fatal  O,,,,;,. 

nitic,  nowhoni  tender. 


23 


nmc,  nowhm!  tender.     Tho  sphrn  (•ann.,t  I,,,  c,  u  .  »i     , 

air  clear  but  fnehlo  "    Ti         V  '^  =  *''^  '"''^''t  '^o""*  >* 

.11.  (liar,  out  leeDle.       1  |,e  patient  took  liis  Iviflw  u,.ll  •  fl.,  f 

tiiir  wuH  very  l.iirl,   ,l„,.i„./  H„.  ,:,  ,  ,  '*•'  '  V    "  '  ""  '"'"I'l'ni- 

;™*- -^V'- .■™:- n;';^  r;L:  ■:!,;;;.;::;:-'- '^^ 
?'■';"■•  '"■;-,  '•"'-"  -'" .0  «A:;::,;;:l^:Trir::;:,s 

fnrly  and  strvcin  ,'1.      Flo  wis  v,..-v  ,]i,li        i    i       "*  J^'^^^"  '"t-oliol 
Mcondweek    .„  hospital,  about   the    ICth  of  J.,|v   the  / 
Ixrame  lower,  and  from  tho   10th   to  tl  o  •  I       '  i  '"".''^"'•'^^'"•^ 

I()-'°      Tl.«  ..l.-i  -iOtli  It  did  not  r  so  al)ove 

lU-  .      llie  alxloinon  was  not  <  istended      TI.,.  .>„!.     i 
verv   feehlo       TI,,,..  "■  le'HUU.      1  lie  pulse,  however,  was 

■.'",;    ,''"'*■  ^^■^'■•'  ••'PI'nrently    no   coniplieations      On    the 
evening,,    of    the    'JOth   the  temperature   rose    t<     10;   5°  '  the 
J~  extremely  .ehle,a^ 

..ive  ofthese  ohlong  ulcers,  1..:^  of  Uiem  ;r^r-bad  ^^tl^ 

enlaced.  ^^^^J^^SJ^^^C:^^:^'^-  T 
-only  slightly  enlarged.  The  kidiu^^^l^^l  :^,/ 1^^  l^^ 
riie  heart  muscle  was  pale  and  flabby.  ■    ■''Wtlbng. 

.|-;.»i  on„e  .0.,,,.,  „-„e,  i,:;^;;™!  t.  r;":i;v-:  v;;;^'  i-^- 


I J 


:J. 


24 


William   Osier. 


24 


Case  II.     Ailviimon  on  1th  dtii/.     Delirium,  kic/k  fever,  irretjulni 
lemperaUwe  in  tJiinl  uwek,  j)rrs!ntnil  roniilinf/,  dinrrlititt,  pandUis,  tlattji 

(lUtojMlf, 

Barhtiru  L.,  aj^t-d  15  (Hos.  No.  150),  admitted  July  '2()tli,  iHsii, 
iibout  the  Heventli  ilay  of  lier  illiies.s,  witli  u  temperature  ol"  105..'1 
She  was  ii  well  nourished,  healthy-lookiiiii  ji;irl.     Tiie  ilhiess  l)(;:;iii 
with  hea(hioheH  and  eough,  and  on   the  2'Jnd  siie  liad  a  ehill.     On 
admission  the  temperature  was  105.3".     Siie  was  delirious  from  the 
outset,  very  restless,  and  liad  marked  nervous  symptoms.    Tiie  ti m- 
perature  was  hij^h,  and  diirinj^  the  first  week  the  daily  variaticms 
were  never  more  than  2  or   2\  degrees.     Towards  the  end  of  tjio 
second  week  of  the  illness  the  morning  and  evening  temperature  uus 
about  102°,  and  the  daily  range  of  the  two-hourly  temjjeraturc  not 
more  than  2.5°.     Throughout  the  third  week  she  was  delirious;  tlie 
pulse  between  110  aiid  129,  the  tongue  dry,  and  on  August  (ith  jinni- 
titis  began  on  the  left  side.     She  also  began  to  have  frequent  attacks 
of  vomiting.     The  fever  during  the  third  week  was  extremely  irreir- 
ular;  thus  on  the   16th  day  there  was  a  drop  in  the  afternoon  to 
96.5°  without  any  eiiill  and  not  following  the  sponging.  It  rose  in  the 
evening  to  103.4°,  the  highest  temperature  which  she  had  hud  for  more 
than  a  week.     Throughout  the  17th,  18th  and  19th  days  of  the  ill- 
ness the  tem|)orature  on  several  oeeasions  was  normal,  and  on  tin; 
20th  day  it  was  subnormal  for  the  greater  part  of  the  twcntv-inur 
hours.     She  had  had  for  several  days  a  good  deal  of  vomiting  mid 
was  extremely  feeble  and  weak  ;  pulse  142.    Throughout  the  LM<;iicr 
part  of  the  fourth  week  this  renuirkable  condition  in  the  tempcratiirp 
persisted,  and  throughout  the  21st,  22nd  and  23rd  days  the  t(iii])(r- 
ature  was  subnormal  for  a  large  part  of  the  time.     Thus  on  August 
10th  the  temperature  at  8  p.  m.  was  99°,  at  4  a.  m.  was  !)lt,(i\  at 
8  a.  m.  it  had  fallen   to  95°,  at  10  a.  m.  to  94°;  it  gradually  rose 
throughout  the  day,  and  between  2  p.  ni.  and  8  a.  m.  the  next  luoru- 
ing  was  constantly  between  98°  and  99".     The  next  day  tlu'ie  was  a 
drop  agaiu  to  95°.     The  pulse  was  during  this  period  not  so  rapid, 
but  extremely   feeble.     The  vomiting  was  persistent  and  i'olluucd 
immediately  the  taking  of  food.   She  was  given  stimulants  constantly, 
and  hypodermics  of  ether  and  brandy.     On  August   loth,  the  2(]th 
day  of  the  disease,  the  temi)erature  began  to  rise,  and  on  the  27tli 
and  28th  was  between  103°  and  104°.     Then  throughout  Aiijiiist 
18th,  19th  and  20th  it  remained  between  100°  and  102°,  and  on  the 


20] 


A  Study  0/  the  Fatal  CWw. 


25 

latter  dite  nlie  dit-d  in  ■•  «.rm.i;*-         /•      ■ 

."'.••-'.-".....:  :;:;;C::::;i;;::;,,"7'''-v.™.n,^^ 

t«o  to  four  dailv.    It  was  mor«  ,.,.... I  .  "'"  '■""^""-  ''•"'" 

"-.     Ti.o  rash  .:•  ,n:W         '""''  ''^""^'""  "'"'  "--•  ^"-'- 

I'lio  special  f«'atiirt'H  of  tlie  case  u<.,v.  fi 
«''  .l-n-i..,  tl.o  second  ^^t  tl'u''  r'""'""^^'  "^"  ^''" 

<i"n-..^'  tl,e  fourth  week,  with  wl  i,  1  •       '      '"  ^'■"'i'<''-"t..res 

"ot  in  any  wav  abate.    T         .  ^  rTT'^^V*  ^'^  "^-'Pton.s  did 

oi.t  sn,,,„„,,ti;,„.  ''"'''  "  '"^'''  •J-^'^'lope.!  suh8ide,i  with- 

^l«/o/«^  (Dr.   Weh.h).     Anatomical  .h--..M.osis  ■    r    ;    •;    ,    • 
UjI'hoid  Imons  in  /..  J  /^  w  L    --^^     V'''     f  "'^  HUration  ;  e.frn.ive 

o^'ory;  .,,>udy  .,.4  :^;!t;:;yr""'  ^^-'  ^  ^— ^-/^^  im^  r,M 

ileo-ca^cal  valve,  and  co„s  ,   ,7    '     '''*'^''  ^'^^  ^'"-  <••""'  t''^' 

l«'<^'"-'-l  f,.n    Is     ere  sw     I  T  ';'""'  ^^  ""'  ^'^^'^'^"  ^''^'  ^'--''^ 

U  ulcers  with  v<Z  Z''::;^'^^^'^^"-  .^^^  ^''<'  valve  were 
"H-'lar  coat  was  evi.l^  ^  T  ^  j.:'::;  i:'-^: '"  ^^•'-"''-  --'- 
H-ll-  and  a  little  un.ler„.i„cd     AlTof  th  T  "T  "'"'"•"^'•'•^■ 

had  the  lonjr  axis  parallel  to  t\L      .1  ''  "'"''''"  ««m^'ti'm's 

— s   .ncn.hran;    fr     .       '    ,      ^"'V'f '"^■^''^'   '"^•"^^•-' '    ^he 
^^""'''«I  ^vith  whitish       th/r  r  r'    '"    *'"   •■'"''""    ^^««    thickly 

wtTOiuore  extensive  ulcers   wifl,  J   "'^''^  <-"•     J"  the  ciccini  there 
"-i'^'mn.    Thcnueo      of-il  ".;      '  ''''"'^  resetuhling  thos,>  i„ 

i-"^'l  --^r  :    t^;;,™'-;-  ''Pl"-^-  -as  swollen  and 
-"'>'■"  'ullicles  were  le.       .!?''•     !    ""  "'''^'^'^  "^-  ■^^-'■'^^''•^-    The 


f 


36 


WUtinw   Oahr. 


[2i) 


rapid  1)ii1ho.  Tin  orgiin  ut-ijilicd  ISO  griunmcH;  tlio  vuIvom  wipt 
noriiKil,  and  tlie  note  I)y  Dr.  H'elcli  on  tlic  licart  muHcle  is,  "niicrn- 
urnpioally  entirely  iiorniiil  ;  .striic  distinct,  no  triit'O  of  i^rannlar  op 
fut<y  «l«';jj('ncration."  An  intcrcstinjj  ueicssory  (londilion  was  iIk. 
h('inorrlnn:<'  into  tin;  stroma  of  tiio  rij^ht  ovary. 

C'ahi-;  Win.  Dotihtfiil  tlnnitioa  licforc  tulmiKmon.  I)i<tf/ii(Min  nf 
eutei'o-volit'iH  ;  sri'nr  ilidrrlifro,  dcdth,  aninpny,  rnpiliillnrii  infiltrtillon  of 
Peyfv'n  fj/iDiih. 

.folm  I/.,  colored,  afr<'<l   -•'>  (Hos.  No.  A.oof]),  iidniittcd  .Fnly   l-Jth^ 
18!(2.     Tliia  patient  was  in    lios])ital  just  a  year    bei'ore   and   wms 
treated  Cor  entero-eolitis  and  recovered.     He  states,  however,  that 
lie  has  since  had  several  attacks,  for  which  he  has  had  repeatcdlv  tn 
*al<e  landannm.      lie  soii^'ht  relief  at   the  dispensary  a  few  days  aird 
for  diarrhiea,  which  has,  he  says,  lasted  some  time,  but  it  wis  iiii|)()j!- 
sihle  to  fix  the  date  of  onset.     He  has  had  some  nausea  and  (ktii- 
sional  vomitini:'.     The  patient  was  emaciated  and   had  a  dull,  stupid 
expres>ioii.     The  ton^ruc  was  covered  with  thick  white  fur.     Tem- 
perature <in  admission  was  102    :ind  rose  to  10.3..')°.     '{"he  alKliMiicn 
was  Hat.     The  condition  of  the  heart  and  lunj^s  was  neji;ative,     Tin 
Mood  examination  showed  no  malarial  parasites.     The  stools  wen' 
examined  repeatedly;   no  amu-bie  were   found.     They  were  tiiiii,  of 
an  amber  color,  and  contained  <j;elatinous  threads  with  I'teeal  iikis.ms. 
Nothing:  spe(;ial  was  seen  on  microscopical  examination.    'I1ic  ('(.joii 
was  irrij^ated  and  he  was  i;iven  bismuth.      During  the  first  three 
days  in  hospital   he  had  a  j^reat  many  stools,  from  nine  to  ten  in  the 
twenty-four  hours.      Typhoid   fever  was  not   suspected,  as  it  wiis 
thought   lie  had  entero-eolitis,  such  as  that  lor  wliicli  he  was  treiited 
a  year  a<.;:o.    Moreover,  the  temperature  morning  and  eveninu.  <in  tli( 
day  after  admission  was  99. "»°,  and  only  rose  once  in  tlio  d;iy  tii  lOl*^. 
Throu,t;liout  the   14tli,  loth  and   KJtli  the  temper-ture  ■V\]  •■  •'  rise 
above   100°.     The  only  suggestive  ])oint  was  the  Uia/.o  reaction  in 
his  urine.    On  tiie  17th  ihe  tem})erature  rose  to  104°  and  he  Ix't'iiine 
very  much  prostrated.     The  diarrluea  was  not  so  severe,  but  thi' 
tiuivements  were  involuntary,  and  he  gradually  sank  and  diid  oii 
:,   ■:  i-Hh, 

'   '■■'"/  ■•'//■     \iKitonucal  diagnosis :    Ti/plioidfcirr,  sUtge  of  mediillarii 
h:Jii'rr'i.o,  i  iciUe  splenic  tumor,  parenchymatoaa  (h'fjeneratioii  of  khhuy'i 

•IVi*  li:"r. 


A   S!turf,,  ,,/  fj„-    Fat,:/  Om^;*. 


27 


r<ritonpiini  Hinootli.     Tlio  I 


walls  tliiHv-(.n..,l       Fron.  t'C   """''    '"/"''''""   "''^     ''■'"*«''   "'"•   the 

I'n.".  l.e»w..,.,.  the  noduloH  was  inN.nso     |.; ..  "';"'";"  """'- 

,„,„„  ,,, I, ,„,,,,     ,       .       '      "'    I'^^Ts   patd.cs    „.,,,,.   intn.srlv 

'.■«i.sint.;;:;;;jL'  .:Se'^  ^.^ 

n<"':s  suTlhnjr;    th<.  „nu,o,,H  men.!,,-,,,,.  U..u  "'"^''■" 

;'■  tl.o  follicles  extended  i.aM..„v  n      I.  ,  '^«';;;  '"'  r-'""^ 

l«.W  weighing  235  granunes.  ''Fh  ,  ,„,.  ,  '  '"  •^'•'•■••"  ^^'"^ 

""■(•h  enlarged.     The  kid,w.v«  „,  "";*''"^'"^'  glands  w,,-.-   very 

;:i;;:;-;-u:*£{? *"-;-«::;; 

.!».. ril,e  li,.„  ,v,,.|r  """■■  ""''■""'»  '■'"■■""I  !'-■ 

»'  F .I.ly  at  ..;,',?         """"  '"■  "'"  '"■"■"■  '""  ■' 

.r.l.o, .4,1  ,oli,a  V  ,1,1   ,,„.  7""  "'""»°«'lili»,a,„l  „,„„v 


28 


William  Osier. 


[28 


I'  ■'-»i 


Wiis  regarded  as  the  primary  lesion,  and  the  dia<i;nosis  was  onlv 
established  post-mortem.  The  oedema  of  the  glottis  occurrod  in 
an  unusually  protracted  case  in  a  pregnant  woman.  The  attack 
came  on  so  newhat  suddenly  when  slie  was  apparently  doing  verv 
Wi'U  and  when  the  temperature  was  gradually  falling. 

Case  I.  Onset  with  rir/or,  persidcnt  high  fever,  hcBinor/lohinuria, 
ikliriuin,  st/inptoms  of  perforation,  death,  autopsy. 

John  T.,  aged  2(j,  colored  (ITos.  No.  54).  Onset  with  rigor,  \m: 
sistent  high  fever.  Ilajmoglobinuria  with  albumin  and  tube  casts. 
Delirium,  symptoms  of  perforation ;  death  on  14th  day  of  illness. 
E.Ktcnsivo  lesions  in  ileum ;  perforation ;  acute  heniorrli:i (;!(.■ 
nephritis. 

This  case  is  i'ully  reported  in  Vol.  II  of  the  Hospital  llo|inrts, 
])age  120,  and  will  be  referred  to  in  this  report  in  Dr.  Hewetson's 
pap(T  on  the  kidney  com])lieations. 

Cask  V.  Admission  at  end  of  second  week.  ^  far  Iced  cardiuc 
arrythviia,  pnei/monia,  death,  aidopsy. 

Johann  R.,  aged  32  (Hos.  No.  469),  admitted  November  2n(l,  188!), 
from  one  of  the  ships  of  the  Hamburg-American  S.  S.  Co.  Tlicn: 
was  a  history  of  an  illness  of  two  weeks'  duration,  with  fever  and 
diarrhoea  and  slight  cough.  He  persisted  in  keeping  abdut  v.\u\ 
trying  to  do  his  work. 

On  admission  he  was  rational ;  temperature  102°,  j)ulsc  78,  vcn 
irregular  and  intermittent.  The  color  was  good,  he  had  no  (lys|ni(P!i 
and  no  cardiac  distress.  There  were  some  jietechia)  on  the  t-kin  oi' 
the  abdomen  and  a  lew  rose  sjwts.  The  heart  condition  was 
unusual,  and  for  the  first  twenty -four  hours  alarming ;  the  im|)iilse 
was  not  forcible,  but  the  shock  was  felt  widely,  the  beats  followed 
each  other  rapidly,  sometimes  in  ]>airs  or  in  series  of  tiirce,  lour,  or 
five.  Many  of  tiie  beats  did  not  reach  the  radial.  The  senmd 
aortic  sound  was  clear.  So  feeble,  intermittent  and  irregular  was 
the  heart's  action  that  he  was  given  several  times  hypodermics  of 
ether,  and  was  at  (mc(!  ordered  digitalis  and  whiskey.  The  lirst 
days  in  hospital  the  patient  was  very  restless  and  delirious.  The 
iieart  for  the  first  twenty-four  hour.-s,  as  stated,  was  extremely  irrcnular 
and  the  action  rapid.  The  rasii  became  very  abundant,  the  petechia' 
gradually   faded,    the  spleen    was    enlarged;    he    had    troublesonic 


V    \V 


hoBmof/loh  initrid , 


Marked  fdrdini 


29] 
diarrhma,  fi 


A  Study  of  the  Fatal  Cases. 


29 


liigl),  ra 


;  hve  or  six  stools 


njiinsr 


i"  fi  flay.     The  t( 


was  s 


'fOJ)J)(.cl, 


patient  soomed  to  be  d 
was  delirious 


only  from  101°  to  103°.     Aft 
iJs  the  piilse  he 


■niporature  was   not 


^r  the  fit],  the  dij-ital 


.         ^^^^^  regidar  l,ut   more   rani 
;"^;vel,tho.„hhehadhaddian.l: 


IS 


and  pneumonia  develops 


I'litil   the  7th  of  A' 


and  after   that  did 
extended  rapidly, 
pneiinioeocci.     The  jjulse  he 


Tl: 


oveniber,  when 


e  tenij.eratn 


'oi-('   rapid.     The 

id'a  and 

si.uns  of  plonrisv 


not   ri.se  above   10'^°    <^i        i 
rn,  ,     ''""^*'    "J'i  ,    tlioiiuh    tl 


ire  rose  to  104°  on  the  7th 


The  reddish-l 


'I'own   sj.uta  contained 


■("une  extremely  feebh 
and  ii 


and 


pneumonia 
nunierou.s 
■•'ip'd,  the 


respirations  were  between  F,n  .,,,,7  m 


Auto]] 


'wy.     Anatomical  diapiosis  .-  7 


krfje  intestines,  loh 


Tl 


v((''  pneumonia,  pi 


morning  oi"  the  9tli 
)ipI)oid  uhm/tion 


HTo  was  extensive  ulcerat 


'eunsi/. 


in  .viiaM  ant/ 


fvon  to  the  rectum.     The  ul 


ion  of  the  1 


;i  rii 
liowcl 

tilt'  V, 


If,  clean  bases;    tl 


cers  were  round  and 


!ii-ffo  intestine,  extend 


iiiir 


ii-regular,  with. 


-—'.-«-;    thoy-  involved  the  entire  Wth  of 
'•     ine  deum  j)resen(P,l  .,vf„..,.: ,         _    ^".-t"  ot 


nive, 


Th 


presented  extensive  ul 


left  liinu 
iileiira 


was 


et.pper  and  posterior  portion  of  the' 
con,sol,dated,andinastateof 


th( 
■oration,  particidarl 


large 
y  near 


ower  lob(>  oftln 


over  it  was  covered  with  a  tl 


nor  part  of  the  lower  lobe  of  the  nVht 


pleura 
0.10 


presented  a  similar  lil 


red  hepatization.     The 

The  posfe- 

■ing  was  also  solid,  and  the 


iin  pellicle  of  fibr 


in. 


grammes.     The  heart  muscle  was  da 


)nnous  exudate.     The  sol 


ITOented  no  fatty  degenerati 


on. 


pleen  weighed 
and  flaccid.     The  fibres 


Case  XI.     Admission  in  sfat,'  nf  ,.,./-.  j  ,  ... 

r^^.-..iai;;-;;^t;!i;::.^,^;:^'^:;: 

•7-'  l-althy  man,  but  cannot  .;,,^^':"^  ''''"'  *''^'^  '">  ''- 
^'It-  States  that  he  has  not  had'^  1  '"^'f  t"*-^-  ='^^«""^  "f  him- 
'--gular;  no  chilhs   n    v^o       i^'';;'''"V':^^  ^''^^  '--'«  ''-- 

-^'-^'>"l^i".  in  aoondi^'o^scSle'dS:"  ^""^^  "'"•^'' 
""re  was  97.5°  at  8  p.  n,     ■xm\  d,M  „.,         f'^»''t}-      Hie  temper- 

='-'f^i^.i-72,r!,uia;/:;L  ti^;::,^^^^^ 

"■''•^-  ''-'vily  coated,  dry  an<l  alu.ost  1  1  d  'n  "'''  ^""^'"'^ 
^■"'aneous  hemorrhages  about  the  wri^ff     ,  ^  "'''"  """'*™U8 

"Clones  on  the  sidn  over     ,','"*'  ^'^''  '^"^^  '"''^^^  «"P^r- 

-^.  The  chest  is  son::,:::, r;:^ 

•"'".ipta,  and  the  lower  part  of 


30 


Williain   (hler. 


[ao 


the  stenuini  is  much  depressed— a  modified  "  trichter-bnist."  On 
tlie  first  day  notliing  was  noticed  on  the  examination  of  the  liiiij-. 
The  heart  sounds  were  clear  ;  second  aortic  accentuated  and  rinuiiii;. 

Note  on  the  abdomen  reads :  "Soft,  irrepilarly  distended,  (he  int<  s- 
tinal  peristalsis  can  be  seen  through  the  thin  walls;  no  tenderness,  w, 
ji:rowth  felt.  Percussion  limits  of  the  spleen  and  liver  are  normnl." 
The  patient  was  thousiht  to  have  a  senile  cachexia,  and  was  ordcrnl 
stimulants,  with  iron  and  nourishintr  food.  The  urine  contaiudi  a 
moderate  amount  of  albumin  with  granular  and  hyaline  (■;l^ts. 
During  the  2;kd,  24th  and  '25th  there  was  fever,  the  teinijcratuiv 
rising  to  101°.  It  was  usually  normal,  sometimes  subnormal,  in 
the  morning.  There  was  no  diarrliani.  Had  no  cough,  no  cNpcr- 
toratiou.  The  ])hysical  examination  was  negative.  On  the  27tli  he 
began  to  have  diarrhoea.  lie  was  unconscious  ;  tongue  very  dry  :  In 
passed  the  urine  and  fteces  involuntarily.  The  ecchymoses  on  tlip 
chest  were  more  extensive.  To-day  it  was  found  that  thejiorcnssion 
note  at  the  left  base  was  dull  as  high  as  the  angle  of  the  scapuhi. 
Respiration  was  tubular,  expiration  prolonged,  and  there  were  a  ll  u 
rales.  It  was  then  thought  that  it  was  a  case  of  jwicunionia  in  ;ui 
old  debilitated  individual.  He  became  progressively  weaker  on  the 
28th  and  died  on  the  morning  of  the  29th.  The  diagnosis  \va> 
pneumonia  in  an  old  man. 

Auto(mi  (Dr.  Welch).  Anatomical  diagnosis:  Typho'ul  fm,: 
Remit  croupous  pneumonia  of  the  left  lon-er  lobe,  enldrc/cd  xiileen,  (/(ill 

stones. 

Peritoneum  smooth  ;  the  peritoneal  surface  of  the  ileum  near  the 
valve  was  covered  with  streaks  of  dark-red  hemorrhagic  infiltration. 
Tiie  small  intestine  ))resented  a  number  of  ulcers,  the  largest  were  in 
the  lower  part  of  the  ileum.  They  were  irregular,  nearly  always  as 
dec))  as  the  transverse  muscular  coat,  and  with  little  or  no  thickening, 
and  without  adherent  sloughs.  Many  had  dark-red  liciiiorrliiii'ic 
floors.  One  occcu])ied  the  margin  of  the  ileo-ctecal  valve.  Tlicy 
extcTided  upwards  for  a  distance  of  50  em.  There  were  also  many 
small  follicular  ulcers.  The  edges  of  the  ulcers  were  but  little  wwlvr- 
mined.  In  the  ciccum  and  beginning  of  the  colon  were  several  small 
ulcers  ;  glands  moderately  swtdlen,  soft.  There  was  no  tviicc  of 
tubercles  over  the  ulcers,  which  were  undoubtedly  tyjiluml  iii 
character. 


31] 


A   Stnrh,  of  the  Fatal  0„e,. 


ypleen  was   soft   and   we,V|,i„.   .(JO 

"-  "  "-  '^"^  lower  Iobo\':'  iS'V"?^:''-^'— soH  a- 
oa-.._oan,e,  thought  very  natu,.  ..:/*■•  '""':"•'  "-'-  -hose 
'levHojm,.  p„,„^,,„j     .;  J  tl'.'tit  was  an  insfance  of  slowly 

-"  -"-'-l,  n-as  seoondar        t^it'  • '  • '  "  ^^"'"'"■'^  ^^^^^'^ 
;-  <  .V.S  befbre  death,  .on-c„rre         I      ,:;:"':";  ''  -''"^^  '""".  two 
l-e  ol.ta.ned  as  to  the  length  of  ti  „e  U^Tlf'r  ''^^"■''^  -"'<! 
■n  -esnn,  to  note  the  low  ten.per  n    V    O     .    "^  ''""  ■'''•     ^'  '« 
;•''"»  ^''^  first  three  davs  he  l^'uT         I  '"""'  "'"  '^^''^  ^'«'««ions 
heJo"-  98S  and  once  uas-gr./o"'  ,;,";'>>;"    the  ten.peratnre  was 
'■^'n  only  once  did  the  ten>,,erature  r    1  T '   '  " ""'  ""•'^''  '•'>«^rva- 
-'--"s  hemorrhages  werl  «u  h  as    1       "'  /''°-     '^^'"''  ^-^ensive 
tracted  cachexia  of  elderly  people.  ^'"^""'^'>-  '"  ^he  pro- 

Case  XVJ.     Jf/,„/,,,/^,,   -^^ 

Annie  M.,  aged   '^3  (JJ  ,■    v 

P"'i™t  was  transfe;ed  to'th^  nielne.!?'  -'f";!'"'  ^"»"«ry  1,  1892. 

-Uo  which  she  had  been'X  ^i'^    "'?  ''''  gy.-colo.ica 

;  'p-  and  nuUaise.     She  had      '  .h^"'  '"''"•^'  -'"Plaining 

M.ad  had  one  child,  iwl  ,  1'  "  •'  "■'""^'" '  "'«med  at 
^P-ionsly  felt  well.  H  .'^d  iT"  ''^'^  ^'^^-'^<>-  «he 
:'  ?•''''-;'  ^  'ver,  with  relapse.  Sell  T  'T'''  '"'  "»  ^^tack 
''^-    Healthy  lookin.  ^vell  nour  ''"  ^'""■'■'^''  ^«^-  "«"arlv  . 

^"""'  1-Htitis,  and  thcT  e.^.nu       V";"'"-     ^'^-<><'oM  inte,' 

r'Vf"""-  ^^0.  T,;:;  e^^n.7f --'^'tched.  Ten,:;. 

;n^y<l-.ended.     The  nter;;    a      ; ",       ?•     '^''^  «»^^'""-n  is 
Y^"'  -onth  of  p,,,g„ancv.     Ti  ere  •  ;    /"  -^''f  '""■^'""  "'"  «hn.,t 
'™'^^^^^  The;,,I,;,   •  •■'*'™^  rosesj.otson  ,he 

"'^' '''"^'' '''^  «- is  accl:^;";;;:::^;;'';"^'^:  heart  sonnds 

•^  'I  '^ott,  blowing  nmrnuir. 


'TMltl 


!# 


^ 


>J    t 

t 


^i    * 


32 


William   Osier. 


[.■5:i 


The  urine  contninerl  no  albumin.  For  the  first  week  in  liospital 
she  had  no  special  features  except  the  jKTsistont  liitrh  fever,  w  hi  el  i  was 
not  nuioh  controlled  by  tlie  batiis.  She  was  rational.  'I'hc  pul-c 
ransred  from  104  to  112;  slie  had  no  diarrhwa.  Ai'ter  tlie  l!)lli  sh, 
did  not  take  the  baths  well,  and  considering  her  condition,  it  \v,i> 
thou<rht  well  to  substitute  the  sponging  for  them.  During  the 
second  week  in  hospital  the  tem))erature  was  lower, only  oceasionallv 
reaching  104°.  The  ])ulse,  however,  was  feeble  and  she  hail 
emaciated  very  much.     She  took  stimulants  and  food  freely. 

On  January  SOtli  tlie  temperature  sank  to  and  remained  at  100°  fur 
1()  hours,  and  on  the  olst  it  fell  to  98°.     Siie  was  quite  rational  and 
took  her  food  better.     During  the  third  week  in  hospital  she  bccanK. 
worse;  the  temperature  kept  persistently  high,  l)etween  10-1^  and 
104.5°.     She  had  no  diarrhcoa.      in  tlie  fourth  week  the  fever  |i(r- 
.sisted  and  she  began  to  have  for  tlie  first  time  delirium.     Tlierc  liad 
been  no  distension  of  the  abdomen,  no  diarrluca.     The  r'    "  spdts, 
of  which  there  had    been  several  crops,   had    almost  disappeared. 
The  foetal  movements  were  distinctly  felt.     On  February  Kith  there 
was  a  fresh  crop  of  rose  spots  noted.     The  temperature  kept  persist- 
ently high,  constantly  reaching  104. .5°  and  rarely  sinking  to  ]01°, 
The  pulse  ranged  from  130  to  140.    On  February  22nd  she  seemed  id 
be  somewhat  better  and  temperature  had  been  tiilling.     For  a  lew 
days  she  had  been  much  troubled  with  hoarseness,  and  with  diarrlapn. 
On  the  22nd,  23rd  and  24th  the  temperature  was  between  100°  and 
100.5°.     On  the  morning  of  the  24th  the  patient  became  verv  hoarsp 
and  could  scarcely  speak  above  a  whisper.     By  noon  there  was  verv 
marked    difliculty  in    breathing.     It  was  very  diflicult  to  make  a 
thorough  examination  of  the  larynx,  but  there  seenu'd  to  be  a  con- 
siderable degree  of  cedema  about  the  e))iglottis.     At  8  o'clocik  tiiat 
evening  Dr.  Halsted  performed   .racheotomy,  with  temporary  relief, 
but  during  the  night  she  sank  rapidly,  and  died  on  the  50tli  dav  of 
her  illness. 

Throughout  the  attack  the  urine  contained  a  trace  of  albumin  with 
hyaline  and  granular  casts. 

Autopsi/.  Anatomical  diagnosis  :  Typhoid  fever.  Ulcers  healing 
and  otlieri^  in  profprsx,  IjronJio-pncumonid,,  pregnane}/  at  si.rtli  monlk 
(cerehral  hcniorrliae/e  offodus,  general  oedema  of  fcetus). 

Extensive  ulceration  in  the  ileum.  The  larger  ulcers  had  circular 
outlines,  but  with  low,  not  verv  well-defined  edges.     Thu-e  was  :i 


ofallniniinwi 


^^tudy  of  the  Fatal  (Uses. 


33] 

^"-^  "J  "'«  i"Hal  Cam.  33 

very  large  ulcerated  surface  near  th.  v.l 

"..est.„e  there  wore  ulcers  ul.ich  .a  ,T,  ^^"^''""  "''  '"  ^''« 
tt'--o  were  eon.pletel,  healed  Ic"  ^Tf  'rY'  ^"'  '"  '>^-- 
contact.     The   mesenteric    ^AJaTZ"  '  "'""=''''*»  ■"  ^''"«e 

<'"l--g«l,  weighed  250  .ram^ur  The  l- 1'"''  •'  ''''''''^'''-  «P'^-" 
numerous  small  areas  on  the  surface  ' '"^/'"'^'^/^^^  Palo ;  there  were 
-•rounded  by  areas  of  hvpen  .•.;•"  "'""""  '""'^^''^'^  ''-^'•- 
containing  the  typhoid  bacilli      Th.""'"  '"""''  ^^  '^^'  "^-^^'««- 

Afarked  cedema  and  con,r,.«f;.       '  ^  ^'^"y  degeneration. 

rose  again,  and  on  the  8lh  a„,l  ,„,"  T      * ' '"''"""I"™"J- •''«  fever 

CEdenia  of  the  L'iotHa  ;a  .,  „ 
.!'«  -ha,..ive  Xu  b     L,'™:™?    :t'::^'rP'-.<>«  fever.     I„ 
«ere  senous  laryngeal  co„,plieaH„„.   i    «  ■"''"P""'*  '"  "Wdi  there 
"ly  8  cases  the  condition  ™  t:,!™  j.lill:*™  ™  ""™'-    '" 


III- 


-ACCIDENTS   OF   THE   Lesiox. 


Hemorrhage.— Of  the  '>9(t 
tl;e  bowels,  three  of  which  pfo'ventar^';'  'f.'  '"'""^'^Se  fron. 
eWery  man,  admitted  on  the  0  h  ^l!  o/h  • ''^ '"*  '"«^--' - 
attack,  with  severe  diarrhcea  nndM  "^  ^'^ '""^««' ^^d  a  sharp 
aeath  followed  shortlv  af^.;  ver.  ^^  J'^''^.  '"  *''^^  ^^-^'^  ^veek  ; 
^o«-ol«.  In  the  seeon'd  ca  e  \  vo^  ^  '"  i'emorrhage  from  the 
'-t  two  or  three  weeks  befo'e  aT^  "'"  '"^'"  ^"^  ^'"'  '"  ^^'  -' 
'Hmorrhage  the  day  after  ,sadm"""  ''\  ''"^'"^='^'  ^"-^  ^  large 
"--.  In  the  third  case  ^llrUmJ'''  '''''''  ^-"- 
^'"fl  't '«  given  in  that  section.  ^'      ''^  ''^"  l^^rforation, 

Cask  VIII.     Admimon  on  JO//,    / 
^■o>niti»ff,per,i,tence  of  fever  in  4, f        ,  ^H^orhosa,  occasional 

'^'-^■^'  <l'-tl,,  no  autops,  '''  ""''  ^"'''^«-  ^-"^orrka.e  fron.  the 


I  A 


iih 


Il 


I 


34 


William  Osier. 


[31 


Charles  B.  li.,  aged  51  (IIos.  No.  1450),  admitted  July  7,  1890, 
about  the  10th  day  of  an  illnoss,  in  which  he  had  had  diarrhoea,  fever, 
cough,  and  several  oliills.  lie  had  also  had  at  the  onset  very  ohsti- 
nato  vomiting.  During  the  seooud  and  tliird  weeks  the  temperature 
ranged  from  100°  to  103°.  The  tongue  was  not  dry,  the  jjulse  was 
of  fair  volume,  and  the  general  condition  was  good.  He  had  no  had 
symptoms  except  that  the  stomach  remained  a  little  irritable  uimI 
he  had  an  occasional  attack  of  vomiting.  No  rash  was  noted.  In 
the  fourth  week  the  fever  did  not  abate,  the  pulse  became  UK.rc 
rapid  and  feeble,  and  he  had  diarrhoea,  from  five  to  eight  stools 
daily;  on  the  loth  the  tongue  became  dry  and  coated,  and  nervous 
symptoms  were  marked.  On  the  16th  he  had  a  graduated  to])i(I 
bath.  On  the  16th  his  temperature  rose  to  104°  and  he  had  another 
bath  at  80°  F.  On  the  morning  of  the  17th,  following  a  profuse 
hemorrhage  from  the  bowels,  he  became  collapsed,  and  in  spite  of 
stimulation  and  hypodermics  of  ether,  he  did  not  rally,  and  died 
the  same  evening. 

There  was  no  autopsy. 

Case  X\^.  Adm^mon  in  third  week.  High  fever,  rapid  pulse, 
meteori.vn.  On  second  day  severe,  hemorrhage,  recurrence  on  third  day, 
death,  autopsy. 

Patrick  W.,  colored,  aged  23,  laborer  (Hos.  No.  4192),  admitted 
November  7th,  1892,  complaining  of  diarrhrea.  Had  been  a  vcrv 
healthy  man.  The  present  illness  began  three  weeks  ago,  witii  diar- 
rhoea, six  or  seven  stools  a  day.  He  had  had  chilly  feelings  and 
pain  in  the  back.  He  had  not  been  able  to  work  for  the  j)ast  twenty- 
five  days.  He  was  told  that  he  had  a  high  fever  and  two  weeks 
ago  he  was  delirious.  He  has  had  also  a  slight  cougli.  When 
admitted  the  j)ulse  was  extremely  weak  and  rapid.  The  temperature 
was  103.5°;  tongue  was  heavily  coated.  The  abdomen  was  dis- 
tended and  tender;  the  sj)leen  was  enlarged,  readily  paljialjlc;  ;lie 
blood  examination  was  negative,  and  there  was  no  leucocytosis.  He 
was  bathed,  and  the  baths  acted  very  i)romptly,  reducing  tiic  tem- 
perature from  three  to  four  degrees.  On  the  8th  the  temperatiue 
was  between  104°  and  105°;  the  pulse  extremely  rapid,  between  J30 
and  150.  The  heart  sounds  were  feeble,  but  clear.  Abdomen  was 
tMise  and  tender  on  pressure;  slight  trace  of  albumin  in  the  urine. 
At  9  p.  m.  he  had  a  large  hemorrhage  from   the  bowels,  pas-siug 


38] 


A  Study  of  the  Fatal  Cases. 


35 

many  clots,  and  all  „ight  there  wis  mnr, 

morning  of  the  9th  ho  loola'  it^    n"'  ^  ""'""^-     ^^"  ^^e 

quietly.     The  pulse  was    4       er'  ■         '      T""'''"'  ^"*  ''''  ''^'-P'"^' 
t'K'  large   hon'orrhage    the"'t  n' e  ^    "      '"''''''''■     ^"  ^'"^^-^ 

tl.e  night  it  ranged  between   loi./o'^' -.Mos  ,o"t."''  '"■""^''""* 
rapidly  through  the  dav,  and  died  -it  nin/       ?k'  '  '""'""*  '""^ 

>^'>out  48  hours  after  admission        .  "?  '^'  '''''"'"•'^'  "^"^''^  ^th, 

disease.  «^l'»>-^^>on.  and  on  or  about  the  28th  day  of  the 

Autoimj.     Anatomical  diaraosis-   T„^i    •>     , 
acute  broncho-pnamonia.  ''^""'  ''^"^''^'t^on  of  the  ileum, 

Peritoneum  smooth.    There  u-.,«  „^  •  ,   ,. 

^ines.  rn  the  ileum  there  v";;  ,1"^  l"'^'""""  "^'^''"  -^- 
^'"'I  ""morous  swollen  soliti    •  Vn,!  ">««r«  ^vith  sharp  edges 

latter  had  greatly  ole^M  ^e  iH^n?  ff'  ■  '"'"^  ""^  ^« 
anoe.  The  solitary  glands  .^  T^^^:;^^'  'T'^'  T''- 
showed  superficial  necrosis  at  the  apices    Tl,  "^''  '""'^  ^''''^^ 

tt'f'  '"ost  extensive   ulceration      T  ^''« '^""g^ '"destine  showed 

"leors  .ith  clean  bases      T:,cr";;  "7    "^"""^'^^   ^■^•''■-' 
(a<-withareasofnecrosisriL.  ''•''''''''""■'  ""''''  ^*'«  «"'- 

"''•  -Kl  there  was  soTe  Itv  ^  il"  ;•  "^'"  ''^  '"-^^  '*""-•  '««'<«d 
=''-'t  them.  The  soTrce  of  .t',  "  ^'"  '"■"'"'•^  "'^"»'--- 
^ands  of  the  mesentery:::^  ^  a  ^tl^::?  not  discovered.  The 
the  valves  normal.  The  musd.  ll  '''""'•,  ^^''^^ ''^art  was  pale, 
The  lungs  showed  at  L  b"e  .  ""  ^''^ '^/^'^^y  degeneralion. 
■'V  brain  and  cord  sho!!:,':::,:^:^"^'^^  '^^  broncho-pneumonia. 

'l».l«  from  .his  ca,,,;,.,.-    „   :„-*of'r'  T"  """""■""  '" 
«m.  Or.lK.d^.hto  .      ,.     r  '™'"''''''  ™"»^-'3.4  ,,or 

*ra,.  colleclcl  oas™  ivas,  however,  as  l,i„h  as 


11 


•^'■■5^-^^ 


11 


I 


36 


Willi(i)i)   Onlev. 


[36 


The  time  of  the  occurrence  of  the  perforation  in  tiiese  eigiit  eases 
was  as  foHows :  in  tlie  8th  week,  1  •  in  the  7th  week,  2;  in  tiic  Tjih 
Aveek,  1  ;  in  the  4th  week,  2;  at  end  of  seeond  week,  "_'. 

In  every  one  of  the  eases,  as  may  he  gathered  from  the  notes,  tlie 
attack  was  severe,  and  in  more  than  one-half  of  tiiem  protracted.  In 
six  cases  the  symjitoms  of  perforation  were  j)resent — pain,  inereasinj; 
abdominal  distension,  and  collapse.  Tn  one  case  (\XI)  tiie  abdomen 
was  retracted.  In  two  cases  the  conditicm  was  unsuspecited,  tiioiiuli 
in  one  (case  IX),  in  which  the  appendix  was  perforated,  there  was 
great  pain  in  the  right  iliac  Ibssa. 

Perforation  of  the  appendix  in  typhoid  fever  is  not  very  (iommoii, 
3  per  cent  in  the  167  eases  of  perforated  bowel  collected  by  Fit/, 
who  remarks:*  "Clinical  evidence,  on  the  contrary,  though  perluips 
misunderstood,  is  abundant  as  to  the  probable  frequency  of  perfora- 
tive appendicitis  in  typiioid  fever.  The  ])robability  of  its  occurrence 
furnishes  the  best  solution  as  to  the  i)rognosis  of  intestinal  perfora- 
tion in  the  latter  disease.  Most  of  the  cases  of  recovery  from 
.symptoms  of  perforation  of  the  bowel  in  ty))hoid  fever  are  those  in 
which  an  attack  of  appendicitis  is  closely  simulated,  while  the 
fatal  cases  of  perforation  of  the  bowel  in  typhoid  fever  are,  in  a  great 
majority  of  instancies,  those  in  which  other  parts  of  the  bowel  than 
the  appendix  are  the  seat  of  the  perforation ;  hence  the  prognosis  of 
apparent  perforation  of  the  bowel  in  typhoid  fever  is  to  be  regarded 
as  the  more  favorable  the  more  closely  the  sym])toms  and  course 
resemble  those  of  an  a])pendieitis." 

Case  IV.  Admismon  in.  third  urch.  Hemorrhage  from  lioirrk, 
prof/rcmvc  adiienia,  /}erforatio)i,  death,  aidopxy. 

Zachariah  L.,  aged  40  (Hosp.  No.  319),  admitted  Se])teinl)er  '21, 
1889.  Tiie  patient  applied  at  the  surgical  dispensary,  and  while  wait- 
ing became  very  weak,  and  had  a  large  bloody  stool.  When  taken  to 
the  ward  he  was  extremelv  feeble,  and  stated  that  h(!  was  a  sailor  bv 
occupation,  and  had  not  worked  for  three  weeks  on  account  of  fever 
and  diarrhiea.  No  further  history  coidd  be  obtained.  Temperature 
on  admission  was  101°;  pulse  92,  dicrotic;  tongue  was  furred,  not 
dry;  the  abdomen  soft,  with  a  few  sus])icious-looking  spots.  Tlic 
heart  sounds  were  very  feeble,  the  first  particularly  weak,  and  tliciT 
was  a  systolic  murmur  at  left  border  of  sternum.    lie  had  no  further 

•Transactions  of  tlie  Association  of  American  Piiysicians,  vol.  vi,,  p.  209. 


V,_ 


;!7] 


^'1   ^tudy  of  the  Fatal  Ca,e^, 


.37 

blmlinj,'  throujrl,  the  day   ami  «„       • 

ently  drowsy.     On  tho  80th    \u\  ^   '  ^"^  *""  "'««  I'^^sist- 

-^  the  first'two  week         Oo      ."/'''"''''"'  '"  ^"  ''°-     '^^''-"Sh- 
«l<iiri..n.  and  rapid  ,,  ds  ^d   '  "'".^'^T  '"'''"'  "'■^''  ^^'^^-^ 

h"  '.ad  marked  tren.or  of^^'ll^lt^r "--«''  '""^^  "^'*''''  -<' 
was  irregular,  between   100°  and  10'^°     "n  ^'''»l'«''"ture  range 

uas  extremely  feeble   the  fp„.»      .         ,"        "'"'"f''  *''«  Ja.st  week  he 
.1-.  from  tl,e  ^5,;„     ,"''';'"'";'''  ^■"■^■'"''-""  ™"""»"»^ 

!..■  <li«l,  it  w,,«  !.8=.  iC  ,  ,  rr '''™"""'-''  ™"  "■'  'I-"  ->-'<!,  when 
»"  »l.«i«l  nl.d„,m„„,  sv  t™,  tZ  :  "■"" ,""  ■'■»"''«'  •■'"" 
«■' He,  »ml  el,e  |,„l„„  rapid   uo  ''""°''''  "■"''  '«'«""=ly 

Ab«„t  7S  oc.  of  v.|l„„.  ,  ',i^  fl  T    T    "^""""'"'"''''""■'■''■"^ 

»'>'■:•  i"-,i„e.  ass,„.i,:;,;:r '  ^  :,  :rf ""-  '"■-  «°"^ 

-I'-miK  tl,c  ,,mto,K.M„,.     r„  lower  oart    f    |     '    Z  '^"  "'"'I'"'  "" 
<ivc  iiregnlar  iilcors  „  iti,  „„„„,!  7     „  """■"  ""'=  <''"™- 

l»yer,.    Tl,„  odges  wo".     ,1         1"  ','  "'"'''"«  ""=  ""«"'- 

Many  of  „.o  ,fl„o,.       0  !   Z    '"""™  '""''""■'V  "-«l'-«°". 

150  c,„.  fro,,,  ,1,0  valve  ,,e,'',r,  r""™'*  ■■    '"'-  '"«''«»'  "l«^. 

» »..  in  ie„«,i,. ,:  irr,  r ,, tz ""-tt  '''"■"«" -«' 

"»;f  .k-re  „„»  aU.-l.olf„;'rTo;::l!„:'  "■'  •-""■   •*'  *'  "<"'"■•  °f "-» 

Hgi..  io..r  ioi,o, „.it„ :,::::',:;,'  :■,:; ;r:  i:;:T:'h"'°" '" '"« 
>«»o.  si,e;:i:'„  v;o!z.  .^r;„^,»;  '^''''  "'""i"'"  ■^'»-i.  5. 

.      ctnth    „me  to  ll.,s  country ;  had  been  ill  for 


.il 


S8 


William   Oder. 


[38 


k:  ^ 


a  week  with  pain  in  the  head  and  back,  coiijjh  and  fever.  It  is  dilli- 
cult  to  say  exactly  how  \im\i  she  has  l)een  ill,  but  she  says  for  not 
more  than  a  week.  .She  had  coniplained  of  a  ^jood  deal  of'alxloininal 
pain,  and  as  there  was  distiirbanee  ol' menstruation  she  was  adniittdl 
to  the  fiynecolotjical  ward.  When  transferred  to  us,  the  tempera  tun 
was  103.5°;  the  abdomen  was  liill,  tense,  and  tender  on  pressure: 
pulse  120.  The  abdominal  distension  was  so  }j;reat,  with  a  tympany 
extendiujito  tlie  fifth  si)aee  on  the  right  side  and  obliterating'  the  llvi  r 
dulness,  that  Dr.  fiatleur  thought  that  possibly  j)erforation  had 
occurred.  On  the  (Uh  at  10.30  a.  m.  she  had  a  chill  lasting";  a  hwW 
hoiir;  complained  of  very  severe  abdominal  ])ain.  The  tem])rratiirc 
was  101.5°,  and  only  rose  by  1  o'clock  to  103.5°.  The  note  i)y 
Dr.  Lafleiir  on  the  (ith  was  as  follows  :  "  Complains  of  seven;  abdom- 
inal pain;  respirations  48,  shallow ;  expiration  f>;roanint,s  pidselfiH, 
compressible  ;  skin  hot  and  dry  ;  face  slifjhtly  flushed,  not  anxious- 
looking;  tongue  moist,  with  a  brownish  fur;  pupils  equal.  Lun^^s 
present  a  few  moist  rales  at  the  base.  Tli(>  heart  sounds  arf 
fffital  in  character,  very  rapid,  possibly  a  soft  s  -s.olic  murmur  m 
the  apex.  The  abdomen  is  uniformly  distended,  ri;!;id,  very  ensi- 
tive  in  right  iliac  and  lumbar  regions;  l)owel  tymi)any  extends  to 
fifth  interspace,  and  in  the  nip|)lc  line  the  liver  dulness  occupies 
only  three-fourths  of  an  inch.  The  spleen  is  not  palpable.  K*opc 
spots  present  on  back."  The  evening  temperature  on  the  titli 
rose  to  103.5°.  Throughout  the  morning  of  the  7th  the  teiii|)(r- 
ature  fell  and  was  98°  at  12.30  a.  m.,  then  gradually  rose  throiij:h 
the  morning.  At  the  visit  the  patient  was  sweating  profusely, 
looked  collapsed;  face  j)ale,  hands  blui.sh;  pulse  170,  thready  aiul 
very  compressible  ;  respiration  shallow,  rapid  •  mind  perfectly  clear. 
The  liver  dulness  was  practically  obliterated,  'i'he  temperature 
between  10  a.  m.  and  7..30  j).  m.  ranged  from  104°  to  105°. 
Tiiroughout  the  early  morning  of  the  8th  it  fell  and  at  2.45  a.  in. 
was  96.5°.  It  rose  at  5  a.  m.  to  103°  and  fell  again  at  »)  a.  m.  to 
96°.  At  8  a.  m.  it  rose  to  104°.  The  patient  on  tiie  8th  was  some- 
what cyanotic,  with  cold  extremities.  The  temperature,  however, 
kept  up  and  was  between  104°  and  105°.  The  heart  sounds  were 
fbt'tal  in  character  and  extremely  rapid.  On  the  morning  of  the  Htli 
the  temperature  rose  to  106°  and  she  died  at  12.45. 

Auiopay.  Anatomical  diagnosis:  Typhoid  ulcers  in  the  ileum  and 
coBOum,  perforation  of  ileum  in  three  of  the  ulcers.  General  puruleM 
peritonitis.     Sacculated  peritonitis  between  the  liver  and  diaphraqm. 


ILI^. 


.'59 1 


A  Slludy  of  Uic  Fatal  (hses. 


39 

Tlu;  coils  of  intestines  .ere  .natt J  ^ ^  j^.'"  t^    '"";'■  '  "y'^^' 
().rlorn(i()i,.s  were  seen      Tlw  ,li.„        ^^"'"-    ,^"  st'paratn.jr  tlioni 

ponclod  to  the  loner   LMt''rT'.:'"   ^''"  ^'^'''*  "•''^'  -"- 
lower  bonier  of  tl.e  fllllrtl.  ril,  ''  '"''•  =  ""  *''^'  '"''  «>^^  ^«  ^he 

tions;  thefirHt,GOcm.alove   he  it.  \      T  ^"'"'"'"'  P*'^'''™" 

""ovo  ..is  an.  another  a^iuLl'irSI  ^i  rj,  jr^  ''^'"• 
teno  f^^lands    were  verv  large  an.I  soft      T         7^  Jhen.esen- 

.run.mes.     The  heart  was   no    "       t;    /  "  7'^"^'"  -"■"'''-1    156 
muscle  fibres.  '    ""    ^''^^>'  J^'K«'>"'ration  of  the 

acW,  p„,  in  the  „b,l„„,«„  „„d  ,|i,,|,t  Z,l      Tl,  """" 

Iwve  pirsiste.!  until  the  present  „,„.,„  .1  •.  »Jnipt„n,. 

th'oe  Javs  ago.     Slie  1,.,1  frl       ■    f '  ■        ™""""K.  "I'^l"  stopped 
»i.l.ont  any  lln      On  ad!.T""\  "  '*'"  "'""'^  »  <•">•■  "a.erv  Ld 

;"..n..i.,..nt.  Tongue  t,Lu:::LrT:s;:;„;'L:;t''''\""' 

liad  systmiatieallv  everv  tl,™„  1  ,  """  !""'«"' 

al»ve  102.5-,  wee  tZ  t',         m  V'™  ""  '™'l..ralure    rose 

«-  a  few  doubtful     ose      1        ,rT'",    ""  "'"  ''"'  "'"' 


m 


\ 


i 


10 


Willinw    Osier. 


[4(1 


iiiul  feet  Klifjhtlv  cold,  toilful!  dry  iind  luird.  SciiHorimn  very  kIiVIiIIv 
clouded.  At  tlic  l)!is<'  of  the  rij^lit  liiii^' tliore  is  niodified  diiliicss; 
hreiithiiin  is  Hlijilitly  tiibidiir.  Abdoincii  (lislcndcd,  not  paiiil'iil. 
Heart  souikIh  arc  clear  and  rapid.  Patient  passed  stools  inv(»ltmi:i- 
rily  in  tlie  ni^ht.  To-day  she  was  so  feeble  that  the  baths  were  imt 
given.  Thev  were  resumed  on  the  4tli.  On  tlu^  /ith  she  wms 
extremely  restless ;  pulse  small  and  rapid;  mind  clear.  Respiration 
30;  tongue  dry  and  brown;  abdomen  soft,  not  distended,  but  is 
tender  on  pressure  in  the  right  iliac  fossa;  the  spleen  is  not  pal- 
pable. Temperature  in  the  evening  rose  ra])idly  to  10(5°,  and  she 
died  at  midnight. 

The  patient  had  29  baths. 

AiUnjtsy,  Anatomical  diiignosis :  Tjiphnid  ulceration  of  ileum ; 
perfordtion  of  rei-mijorm  uppendix  ;  <icute  peritovilin. 

On  opening  the  abdominal  cavity  there  was  an  escape  of  g;is. 
Large  intestines  much  dilatei'  ;  peritoneum  covered  with  purulent 
exudate;  "200  ec.  of  cloudy  purulent  fluid.  Diaphragm  on  the  rifjht 
side  at  lower  margin  of  third  ril). 

Thejleum  presented  numerous  ulcers  in  the  Fever's  |)atclies;  the 
bases  were  clean.  Some  of  the  upper  ones  had  small  bile-stained 
sloughs  adherent;  swelling  of  the  solitary  follicles.  The  ulceration 
was  very  extensive  about  the  valve.  'Vhe  vermiform  aj)peudix  ^vit^ 
dilated,  and  presented  nunurous  ulcers  with  necrotic  sloughs.  Two  of 
these  ulcers  had  jxirforated,  making  openings,  one  5  mm.,  the  other 
4  mm.  in  diameter.  The  large  intestine  presented  many  ulcers  with 
smooth  bases. 

The  spleen  weighed  230  grammes.  Heart  muscle  soft  and  [mlc, 
easily  torn,  showed  very  slight  fatty  degeneration.  Lungs  intensely 
congested  at  bases ;  in  the  superior  division  of  the  left  pulmonary 
artery  was  a  soft  thrombus.  The  kidncns  were  enlarged  and  .soft, 
and  showed  fatty  degeneration. 

Cask  XIII.  Admixsion  at  bcgimnng  of  second  week.  Modtrok 
fever,  delirium,  ineteorism,  collapse  si/mptoms,  peritonitis,  death,  (iHtop.vi. 

Matthias  (i.,  aged  2(5,  German  (IIos.  No.  3732),  admitted  Anirust 
28th,  189L  Patient  had  been  in  this  country  only  nine  months. 
Had  always  been  well  until  the  present  illness,  which  began  eisrht 
days  ago  with  loss  of  appetite,  vomiting,  fever  and  chilly  sensations. 
On  August  24th  he  took  medicine  to  move  the  bowels. 


1 


U] 


A  Study  of  thr   Fnlaf  CiHei,. 


41 

I'aticnt  Ih  u  larcc.  wrll.Km'U  « 
<li<T...i,..     TI.,.ro  is     .    I L  r    =    '•"''"■'•"^•"•"   •<'^";    I...lso8«, 

--o....e....:^.t:r;:;;:;;::;i;;-tr''-^ 
H'r^>ati.si„  tir;4i;:ur  S;rV" '"'''•''''''"'>• '^^^^ 

<■>.<■«;  thus  a  hath  of  20  mhuitos  at  70°  "I  4  '"'•■  '"•"''"""••«'•  ""l"' 
tl^e  !»th  mined  tho  (..aneratn^o  ,  <)f-o  ,"•  "'•,""  *'"-'  """'"'"^  "*' 
onlv  ri-sen  to  07^  an.l  al  S  '    <,  J  ""."'     7"  ?  "  '"•  ''  ''^'^ 

rapid.     It  was  noti<.cd    H,;.   .  "  ''"'''''  '''''^"•"«  '"ore 

^  ml     h  tended,  rather  tirn,  tyn.panith,  hut  not 

'•--'.■  «^H  the' le: !:::;;  r':r:>;;-'<;;;;^^^^^^^^ 

Karlyon  the  mornin  r  of  the  1(  th %  ''■""'"^'  "'"'*   '^^■^"• 

'"I-',  the  ten,K.ratnr:        c^'o  '"^  ''"  f^'"'V^"^  '"  '"■'"'••"'^l  -'- 

p' -estieLni^ht a:, L,j:.t:;i:i'^ '•:;'',  "^'-' 

'I'^^-l.  ,  tense,  tyn,,aniti,,  an.l  tende/ ,>        ::  ,,  ^tT""  ^^"^ 
Fctcd  that  perihration    had    taken  pl.c,.      Th  ""' 

tliroimh  the  (hiv 'ind  hv  8  ,>         1        '  "-    temperature   rose 

.       "'Y  •'""  ''}  «  !>■  ni.  had  reached  neirlv  104°      rr     r    i 
on  the  night  of  the  10th.     The  urine  io  tl.;«  •  ,'  '''"' 

tl'o  onset  contained  alhunun   wihr<e  .•'"''''■•' '''"'■''^' '"^"^^ 

'"V"""""'  ''^•"^'>""->  "-•  di:;;:etK-t.r;;:!.d"'  '^''-^  ^-^  '"^-'>- 

Peritoneum  contained  "-m-  fl.„  „,„    i 


42 


Willidvi    Oftlcr. 


[4: 


in  diameter,  ill  tlie  centre  of  which  was  ii  round  perforation  2  mm. 
No  ulcers  in  the  large  intestine.  The  spleen  was  enlarged  jmd 
weighed  510  grammes. 

Intense  congestion  of  lower  lobes  of  both  lungs.  The  entire  upper 
edge  of  the  epiglottis  was  ulcerated  and  covered  with  a  dark  hr(i\vu, 
eas^ily  separated  fibrinous  mass.  There  was  slight  necrosis  in  aI•ea^ 
on  the  posterior  wall  of  the  pharynx.  The  heart  was  pale  and  soft, 
the  muscle  not  fatty. 

Cask  XIX.  Admmio/i  in  nccond  wed:  In  fifth  week  of  ilhw^^ 
great  abdominal  pain,  vomiling,  no  pain  or  mcteorium,  emaciation  ;  awl 
in  seventh  week  pain   in    abdomen,   no  .•^wcliinr/,  vomilinff,  dian-haa, 

death,  antopi^y. 

Benthinc  L.,  aged  21,  domestic  (Hos.  No.  5597),  admitted  Julv 
22nd,  1892.     Patient  had  been  a  healthy  girl.     Present  illness  h(.i:aii 
about  a  week  ago  with  loss  of  appetite  and  chilly  feeli.igs  and  fcv.r. 
On  admission   the  temperature  was  104.5°;  pulse   118.     Abdoinen 
was  not  distended,  but  tense.   There  was  a  sliglit  erythematous  l)hisli 
over  the  lower  thoracic  and  upper  abdominal  regions.     Thcs  splem 
could  not  be  felt.     Examination  of  the  heart  and  lungs  negutivt'. 
Urine  contained  a  trace  of  albumin,  and  there  was  distinct  diazo  reac- 
tion.   During  the  first  week  the  temperature  range  was  between  WV 
(after  a  bath)  and   105.8".     The  baths  reduced  the  temperature  an 
average  of  three  degrees.     There  had  been  a  characteristic  rose  rash 
and  the  spleen  could  be  distinctly  felt.     During  the  second  week  in 
hospital  the  fever  kept  high  ;  the  baths  had  a  very  marked  inHueiice, 
often  reducing  the  temperature  five  and  on  one  occasion  six  dcirrco,-, 
The  pulse  was  feeble  and  rapid,  from  IIG  to  120.     The  tongue  wa> 
dry  and  coated.     There  iiad  been  no  abdominal  distension  or  tender- 
ness, and  onlv  lately  a  little   tendency  to  diarrhiea.     In   the  third 
week  the  temperature  was  on  the  whole  soru.o.-hat  lower,  though  it 
often  rose  to  104°  and  once  to  105°.    She  t  ok  f  ,e  baths  well  and  they 
still  had  a  very  marked  infiuence  on  the  ft/er.     The  rose  spots  dis- 
appeared.    The  pulse   had   been   somewhat  better.     She   had  iiiid 
troublesome  boils  on  the  back.    There  was  no  delirium.     During  the 
fourth  week  in  hospital  the  temperature  was  not  so  high,  and  between 
August  13th  and  17th  it  was  usually  between   101°  and   ll)2^aIl(l 
she  seemed  to  be  doing  well.    On  August  18th,  after  a  bath  the  toni- 
perature  fell  from  105.8°  to  99.2°.     The  pulse  rose  above  140,  und 


4;5J 


rforation  2  mm. 


A  Study  of  (he  Fatal  Cam. 


43 

"«■  Patient  complained  of  ...-eat  -ihrln    •     , 

exeremely  weak  condition,  st    hi;      "?      .^"'"'   "''^  -««   "'  - 

g'v™.     Tl.e  temporatnre;notvil''T    ''"'.'"  "'^^^'^^  ''«^l  to  1,. 

"nt.i  -'  a.  „j.  u  fell  and  ..eached  lOl'      p',  '/  ',""'  ''"'"  ^''^'^  ^'"-' 
se  vomited  j^reenish  fluid.     Since  ih.  .  u     ''  '"""'""  ^'^^  ^^th 

of  t,m,.,s  and  complains  of  ah.lon  n  '         '"'"•■^^^'  ^  ""'»'>er 

tl'e  n)tl.  the  patient  was  bettor  thnn  '  "  ""  "^•'  '""^'^""-'t.  On 
^y^  The  ahdomen  .as  ^l^t  t  "  ^  "'"^'  /^^'  ^^^^  "^^  better 
h  th  the  vomitin.  .as  u  tro«b,c,.so„  i,,;^;''"'^'  ^''^  "«^^  "'«*,  the 
what  nervous  and  excited  Thet  ^  '  '"'  '''''^  ^^'^  ^^as  some- 
H'f  ^  but  after  spon.ing  salk^ T'^""  ""  ^'"^'"^^  ^^«^  -sc  to 
abdomen  had  been  retracted  ton  1  '  T""*""'^  ^^'^'''^ '*^°-  The 
l^'tient   was    now    n.^^  ^J^  ^'P'  tender  to  the  touch 

'"""'-l'-'^^-^-  l^>on.  this  in  ;^^^^^^  ^/^=^^--  ^J-wn,  the 
-..■erne  V  irregular,  each  dav  r  ^n  ';:''^^'  '''  '-"P"-ture  was 
'I'cn  ^allmg,  sometimes  to  norm  ,  .  ''"'  ^^^°  '-"'^  ^04°,  and 

f '•  ^^Oth  the  special  tend^;   '    Ir;^^'^'"  ^--'"^  -.^normal     On 
""5  f  -  --  no  distensiot    S     '  "^  ";  ^''^'  *'^^''«-"  --  noticed, 
^'"-l  ^'-  vonu-ting  had  been  severe    On '^h'Tw'"'  "'■'^''"^'>'  «^^W^' 
^;nc.al   condition    had    not   iml.^d         '^^  "''^'^  ^^^^-^  that  the 
Tliere  was  less  vomiting;  the  nu  se  u       ""'""'=»*'«»    ^ad    increased 

'"f^.^- "'oven.ents  during  the  ni^ht      O    .,""'"*  ^''''^'  tive  invol- 
''"'  ""t  rise   above  l()O.V/sl      l'        ^^V''^^ '^^'^t  the  temperature 
I  •«"'«"•  l.st.  '  "'"  ^'^^'^""^  ^^«bler  and  died  on  Sep 

,  /^"^«     Anatomical    diagnosis-     /...    , 

(F//..v,k  ^  '^'•^«'«''".^/  «^«-  ^"  «.yy«o/./  /,,„,,,  /^J^j 

I'eritoneum    covered    witi,    «  i 
'":-«:  .  On  .he  s,>,„„i;"     ,;'';:    ;■-»"•' ^    ''"'e  or    „„   «„M 

-I-    Tl,„  „„g,,  „,„„  ^,„„;™'  "    '■     71-d  ..o  dc,,,..  „,„!,  ,1,, 

"  "*  ""^"- '"  '^»  8-,  and'-  .„:,;r  x  r::;""","-  -- 

I  *^™   "««    "ndermincd 


» 


t    ■ 


I  i     1 


1 


44 


William  Osier. 


[H 


edges  with  clean  bases,  exposing  the  transverse  muscle  fibres,  hi 
the  large  intestine  there  were  no  ulcers,  nor  were  the  follicles  at  all 
swollen  until  the  descending  colon  was  reached.  Here  the  solitar, 
tbllicles  were  prominent  and  showed  superficial  losses  of  subHtaiici. 
At  one  of  these  points  perforation  had  occurred.  The  ulcer  had 
clean-cut  edges  and  the  perforation  was  2  mm.  in  diameter.  Anotlur 
ulcer  occurred  in  the  sigmoid  flexure.  In  the  rectum  there  was  ;i 
large  irregular  ulceration  just  above  the  anus,  3x3.5  cm.  in  size. 

The  mesenteric  glands  were  swollen  and  enlarged  ;  the  spleen  was 
not  much  enlarged. 

Cask  XX.  Admission  about  end  oj  first  locek.  Moderate  J'i'm. 
rapid  and  feeble  pulse.  End  of  second  week,  abdominal  distension  and 
pain;  de(dh,  autopsy. 

Henry  A.,  aged  35  (Hos.  No.  6231),  admitted  November  1st,  1892. 
Present  illness  began  about  a  week  ago  with  pain  in  the  back  n^i  the 
neck,  general  stiffness  and  soreness.  Worked  until  five  days  airo. 
Four  days  ago  felt  very  dizzy  and  had  pains  all  over,  and  has  tilt 
hot.  Has  been  in  bed  for  five  days.  When  admitted  the  temper- 
ature was  104°,  the  pulse  120,  respirations  32.  The  tongue  wasdrv 
and  coated;  there  was  a  well-marked  rash  on  the  skin  of  theabdoiiuii, 
and  the  s{)leen  was  palpable.  The  fever  persisted,  not  nmeh 
influenced  by  the  baths,  only  occasionally  there  was  a  drop  of  iiidie 
than  two  degrees.  The  patient  seemed  to  do  well,  took  his  food 
satisfactorily  ;  the  pulse  was  sometimes  ra])id  and  feeble,  120  to  12i). 
He  was  perfectly  rational.  The  abdomen  was  tender  and  not  specially 
distended.  On  the  8th  the  note  was,  "  temperature  from  4tii  to  8th 
has  ranged  from  100.«°  to  104.2°.  The  temperature  of  the  baths 
was  reduced  to  05°.  The  drops  in  fever  after  bathing  have  not 
been  at  all  marked.  The  pulse  has  been  feeble  and  rapid,  a'ld  the 
patient  has  been  given  stimulants  freely  and  strychnia."  It  wa,' 
noted  to-day  that  there  is  some  tenderness  over  the  al)d()inon.  in 
the  evening  the  abdomen  was  found  considerably  distended,  i)artiou- 
hirly  in  the  epigastric  region  just  below  the  ensiform  cartilage.  The 
bowel-tympany  reached  liigh  and  completely  obliterated  the  liver 
dulness.     The  patient  sank  and  died  at  11  p.  m.  on  the  8tli. 

I  noted  as  follows:  "When  I  saw  this  man  at  12  noon  there 
were  no  marked  collapse  sym])toms;  the  pulse  was  rapid,  hut  not 
small;  face  not  pinched  or  anxious-looking,  and  he  answered  ques- 


^V- 


A  l^tudy  of  the.  Fatal  CW.^. 


45] 

"^  "J   "'K  ratal   Ua.Wi 

tions  readily.     TJipro  woe  .,„•     •      .     . 

.l«'»J»J-    Anatomical  <li;,,,„„si, .  7V,.;,„- ,  ,       ' 

lUUO  cc.  of  turhirl   Hn.M   ■ 

0-  the  coi,s  0^^,!!:'-^!;::-^-^^^  >  fi^nno..  e.ud.to 

i"-t.     At  a  distance  ol"  8  e„    •  bo^  'l.     ''T  '  '"*"''"  ""^'^^  '— 

■^  >'>•  ^2  mm.,  which  passed      "r^'rha^.h"  ""'^  "'   "'^'•■•^*'- 

serous   layer.     The  n  „rn^..  "    ,       ^"^  '^''"*''  perforating,^  the 

^o.nUtheso;;ta;^;s;^,:nr  :x^  ^r  ^^^^  ^^'- 

presented  small  nlcerations      In  flu  l  throughout,  and  son.e 

not  MvoIIen.  The  spleen  vei.]. "l  L  ''"  '"'"'"''  ^''^  '"'"^•■-  "-^ 
little  ,.ale,  butof  go  d  con  is  tn  '^'f  ""'"^'•^-  '^^e  kidneys  were  a 
-1  i"  color  and'looked  C  ;  ^^;;^^-^* -"-•«  was  brownish- 
changes.  "'>•      ^^^  ^""gs  showed  no  special 

Case  XXI.     Admission  in  fourth  w,rl-       nr       ■      ■  , 
!imt  miity  si,ns  of  perforatioi,  ^ Z^,,   f  ^  '"  '''''  ''^''^''''' 

FerdniandW.,agedlS(Hos  io  (hA       i  . 

Patient  had  been  a  healtl/v  nvu,      Prf  '''.m"'"'^  ^^'«^'-  ^^*'''  ^^92. 
ago  with  headache,  which  hafLn  '"''  ^'^^""  ^'^ '''^^ 

been  in  bed  three  weeks  tit,  a'r^^fr""^ '  ""'^^""■-  «^  ^- 
l«.'t  few  days  he  has  had  diarrhea  1^  "^"J'''^'*'^«-  ^^''tJ'in  the 
l.ad  opistaxis  five  or  six  t  „  e  On  -H  •"'  V''^'  ^"^  ^^--''^'^  '"" 
105°,  rose  in  the  evening  to  106°  .p:^^""''^«'«» /''«  temperature  was 
not  emaciated;  temperature  at  the  i^*'' '!'^''^"*  ^""'<-^  ^vell  and  was 
P'.l.^c.  1.0,  small  in  volul  ;  o  irtr"V"'"'"^'"'  ^^"^'^  ''''• 
'""•«'•    There  was  no  delirium     Tf  >^"'  '^''^"^"'  =^  ^'^l^ 

""'i  the  anterior  superior  Inine  ,1         '  """^""^  '^'*^^^^"  ^^^  "^'vel 
»bo'"  ti.e  si^e  of  a  V     ;ur  : ft  InT  T"/  '^"';"^  ''"'"^"^  -- 

|-;-  There  was  resonaneoer  it  t:;!",'  '"^  ^^'"■^'^'^'^  <'" 
We;  heart  sounds  were  clear      n,  .     !      ^''''"  "'"■''  ""^  palpa- 

l-^'«^™tlyhigh,bu  wa  h^l„,f  ;"^'\?^^^  "•«"'^-  ^^^  ftvirwas 
'ion  bein^/from  ^  to  V  W  "  ?:  /"'r'^; '  •^'  ^'"'  ^''^''^'  ^'^  -'- 
"'  i-«Pital  he  became  vefy  m\,el  f'  M  ".  "'^  ^'"  ^^'«  ^'"'^^  ^^•-'^' 
^''"'« -nuMn,t.     He  ha    'bv        ,  r^^"'     ''  ^™''  "^ well-defined 

^'-ges  in  the  mass  in  t'    ^  '     ""'"I"''^ '  '^""^  "^^^"  - 

>^''='t  dry  and  fissured.    O.    ht  L  '•  ""'  '"'^'""  ^^^  -'— 

^"  the  24th  the  notes  as  follows:  "Patient 


i 


.1,,  i 


M 


46 


Wiltutm    Osier. 


[tfi 


is  lying  on  his  left  side  with  his  hand  on  the  abdoracu,  groaning,  eini- 
tinually.  The  al)doinen  is  retracted  and  very  tense,  and  is  pa  in  In] 
on  pressure,  but  after  examination  considerable  i)ressiire  is  borm 
without  much  increase  in  the  pain.  Fulse  is  120,  full,  but  ot  )i,\v 
tension ;  tongue  is  dry,  brown,  glazed.  Yesterday  he  had  six  sfool.s 
fluid,  yellowish,  and  contained  no  blood.  There  is  no  leucocytot-is. 
On  the  evening  of  the  24th  the  tenij)erature  rose  to  nearly  107  ' 
On  the  26th  the  note  is,  "  temperature  remains  elevated ;  the  diar- 
rhoea, which  was  better,  has  recurred.  The  abdomen  is  retracted  :uh1 
tender;  the  pulse  is  small  and  soft;  face  is  ])inched.  The  teni|)(rii- 
ture  rose  to  106°  at  noon."  He  gradually  sank  and  died  in  rlic 
afternoon  of  the  26th. 

Autopsy.  Anatomical  diagnosis :  Typhoid  fever,  perforadou  of 
appendix  vcrmijornm,  jihrino-puraleiil  peritonitis,  ehronia  diffuse  )iepj,r\. 
lis,  gas  hacillus  in  the  hlood. 

In  the  lower  half  of  the  peritoneum  there  was  an  extensive  fibrind- 
purulent  exudate.  In  tlie  right  iliac  fossa  there  was  some;  browniMi- 
yellow  fluid  with  distinctly  foecal  odor.  The  vermiform  ap|)eii(lix 
was  6  cm.  long  and  buried  in  a  mass  of  lymph.  On  examiiiatidii  u 
pin-hole  perforation  was  found  near  its  attachment  to  the  wocuiii, 
from  which  gas  and  fluid  escaped  on  pressure. 

Small  intestine  was  apparently  normal  until  the  middle  of  th" 
ileum  is  reached,  at  which  point  there  was  a  single  enlarged  follicle. 
Peyer's  patches  were  not  swollen  until  35  cm.  above  the  valve.  The 
swelling  was  slight  in  amount,  the  edges  a  little  elevated.  The  lir.-t 
ulcer  was  20  cm.  above  the  valve,  in  a  patch.  Other  uk'crs  with 
sloughing  contents  occurred  just  above  the  valve.  Tiie  ca'cimi  jire- 
sented  many  ulcers  varying  in  size,  some  with  sloughs  atrach<(i, 
others  with  clean  bases.  Many  ulcers  existed  throughout  the  asctiid- 
ing  and  transverse  colon.  In  the  rectum  there  was  an  ulcer ;]  niiii.iii 
extent.  The  appendix  vermiformis  presented  two  ulcers  corn'si)oii(l- 
'  ig  to  the  jHU'forations  menticmed.  The  mesenteric  glands  were 
enlarged;  the  spleen  weighed  210  grammes. 

The  kidneys  weighed  260  grammes  together;  the  capsules  adhe- 
rent, and  microscopically  the  organ  showed  a  chronic  diffuse  ucpliritiN 
The  heart  muscle  was  pale.  The  lungs  were  congested  and  (I'deina- 
tous  at  the  bases. 

Gasp:  XXIl.  Admission  in  end  of  first  week  Mild  atbid-  atjir-i 
in  third  week  liigh  fevtr  and  delirium,  in  sixth  week  much  deliriim '»''' 


47] 


^■'   ^"^tndy  of  the  Fatal  Cases. 


"go  «l,  eo„gl,  and  ,,„i„  ,■„  .H.-  ,,  j,"^     '  '"<»  l^^.-a,,  „•,  „.„^, 
™"   «>"r  day,  ago,  ,vi,e„  ,„      ,/    ;,      '     I"'!"  »'  «„rk,  h„„,„ 

"t  igh,  usually  ..euehing  e  -  dt  to"\^^"^^^  '"  ^-P^tal 
"^99°;  thus  on  the  14th,  lotirund  4t%  n  '"  """'"■""  '«  '^^o 
'-0  ran.e  was  between   990  ,;,^"f;/.^'^  <>f  Deeember  the  tempera- 

-  r'des   disappeared.     The  p„,,se  ta's  no."  T"^^  ""^  ^^'"^^  -"I 
•'""•'•''^«='-     About  the  ninth  davZ  ''^  ^^^'  '"^  ''=^1  no 

-''  it  was  regarded  as  a  1    of    ''V'''''""'"-"^''^'-^--^  ^-e  spot 

--'  --'c  in  hospital  t:;:';::;^^^  '"^^"^•^^•-  ^^--"^  - 

■^--  -i  103°,  and  the  baths        r:!!"  '"^^  ^""^'  -'  ^'-^^th 
wk  the  teniperat.ire  kent  nn  o,  ^  -^'H-<»'g-hout  the  third 

'-  f  ^0^°.  He  tooriir.;:;;;  ;:r"^'  ^?  ^^'^  -^^•''- 

anoe  of  a  patient  severelv  ill.  He  'a  I  '  """  "^'  '^'^'  "''I'^•■"- 
-K  116,  and  of  low  ionsiou  ^'1^^'::;!^:  "?''  ^''«  1-'-  -as 
that  the  baths  were  omitted      H.  I     1  ''  ^'  '^'-^«^"'^'  -^o  feeble 

f;  0'-  ^-or.     He  hadt,  ^tr:T\  'f '""^  ""^^  =^  ^"^ 
:^l^'''>'"«'   was   not  speeiallv   ten  e    V    J^^''  ''^'"^-n-hage.     The 
!;;i'roved  sonaewhat,  so  tha't  the  Mh;    '        "'   ^''''''''"^    '"'^J    ^e 
rhe  te„,perature   throughout  the  fi  „•  h     'T""^'^^  ""  '^''  28th. 
ro.    010  to  103.50.     tie  ren     nS  h^  ""'  "'"  ^^^'■^•-'  ^•""^^-g 
'-  throughout  the  fifti,  week      H    1    d  "V'  the  san.e  eondi^ 
-H^cnerall,  eontr,>lle,l  with  a  pill  oV        """'''•'  '^''"•''"'^''  ^^'''-h 
'"'■^  "«  ten.perature  heoan.e  nol     '       ^     "'""'"•    ^"  ^''^'^'-^th 
;7/'-l-  -ari,  to  normal     ^      Iff'  i;-^  ^-I'-^b'  there 


f   ■'' 


!| 


- 


IS 


William   Oskr. 


[48 


k'litly  ;\<iainst  the  hutlis  mid  the  enemiitii.  Lust  ni^ht  he  complaiiKd 
much  of  ])ain  and  referred  it  to  the  ri,u;lit  iliac  fossa.  Tiie  pulsi', 
which  had  before  ranged  from  100  to  128,  rose  at  7  a.  m.  to  160,  and 
at  8  o'eh)ck  to  1(58.  At  tlie  visit  he  was  in  a  soi)orose  condition,  the 
mouth  oi)en  ;  pulse  164,  small  in  volume  and  low  in  tension.  TIk 
hands  and  the  mucous  membranes  were  cyanotic.  The  patient  was 
evidentlv  v(n'y  much  weaker.  The  abdomen  was  full,  but  not  dis- 
tended, ratient  complained  of  tenderness  in  the  right  iliac  i'ossa. 
The  hejiatic  flatness  reached  from  the  sixth  rib  to  the  costal  niargit). 
The  ])ain  came  on  suddenly  during  the  night,  and  ever  since  the 
patient  has  lain  with  the  legs  drawn  up.  lie  has  also  had  hiccough 
this  morning."  Patient  became  much  worse  in  the  afternoon;  i)ulse 
rapid;  no  increase  in  the  distension  of  the  abdomen.  The  liver  dul- 
ness  remained  as  noted  above,  and  he  died  at  1  ]).  m.  The  tempera- 
ture throughout  the  11th,  I'ith,  13th  and  14th  was  intermittent, 
the  evening  ranging  generally  from  102.5°  to  103°,  and  the  moniiiii; 
ahuost  to  normal.  Throughout  the  15th  the  temperature  was  between 
99°  and  100°  for  24  hours,  and  on  the  16th,  17th  and  18tli  tlioie 
was  very  slight  elevation. 

Autopsy  (Dr.  Jiarker).  Anatomical  diagnosis:  Extensive  fijphoiil 
ulceration  in  small  and  large  intestines,  heal!  j  ulcers  in  mnalt  lioml, 
advancinr/  itlcers  i)i  colon,  ulceration  extendinr/  on  to  skin  at  anus  (md 
into  vesico-rectal  tmue,  pa-foration  of  ulcer  in  colon,  f/eneral  puruhd 
pcfritonitis,  ulceration  of  pliari/nx. 

On  oi)cning  the  peritoneal  cavity  afoul-smelling  gas  escajjcd.  The 
membrane  was  covered  by  a  thick  yellow  exudate.  There  were  300 
cc.  of  purulent  fluid  in  ])elvis.  There  were  many  hemorrhages  in 
the  subperitoneal  tissue. 

No  ulceration  in  the  jejunum;  the  first  ulcer  occurred  120  em, 
above  the  valve  and  was  in  process  of  cicatrization.  17  cm.  below 
this  there  was  a  second  ulcer  with  more  advanced  healing;  12  em. 
lower  down  there  was  a  large  ulcer  with  a  cleati  base  and  iindenuiiud 
edges.  13eginning  145  cm.  above  the  valve  there  were  very  large 
losses  of  substance,  consisting  of  irregular  circular  areas  of  ulceration 
with  perfectly  clean  bases.  Just  above  the  valve  there  was  a  large 
irregular  ulcer  5  by  12  cm.  The  appendix  was  normal.  The  csmim 
showed  superficial  losses  of  substance,  and  the  solitary  follicles  were 
swollen.  The  largest  and  most  nuuierous  ulcers  were  in  the  sigmoid 
flexure  and  rectum.     The  first,  12  by  5  cm.,  was  in  the  lower  partof 


IV 


49] 


A  SMff  of  the  Fatal  Cases. 


49 
tl-e  colon  and  extended  into  the  reetum  U.  I 
t'"'  """«.     The  base  of  this  Ts  '    ?'  '''  '      ^'"'"'^  ^  '"'■  ^'•""' 

evnvnvhere  exposed.     I„    h  ^o'  tl  n''  "1  '''  ""-"'-  - 
-■arly  to  the  serosa,  and  in  tl     oe„t  a     'T^  ""'  ''''''''  -^^«»ded 
'  ••;-•  -•"  diameter.     .r,.st  b    ore ^     ,0"      "?  ""^  ^  ^'^'-^--^-n 
reached  there  was  an  irreLnd ,  '"'"  '"'^  "^'  this  ulcer  w.s 

f-';  between  the  -c;:^^ cr^f j"^ /»-  ^he  cell,;;:: 

i-e  had  a  dark  sloughv  uppearanee   bit   h  '^'''-     '''''  *^"««"« 

anus  and  extending  on  the  kinTor  a  I  ''  ?'  "'  P"^"  ^^  ^^e 
0^  one  and  just  i„,piugi„,  i„  .  «  e  fth"  '.  '•'  ""•  ^'^  *''«  -- 
»>;Ji  pigmented  edges.  ^  ^^^  "^^''i-'  were  two  ulcers 

There  was  an  irrpfmln..     i 

t-'e.    The  spleen  weighed  21otatiesr^^^^^  '"''  '""^  ^"b^"-- 
-;e  swollen,  the  substance  coarsf  aTd  ?h  1 ""  '"''    '^*'«  ''^^^^y^ 
.    The  heart  substance  was  moderateh  fi        ^  "''''  "'''^''^' 
•nt.">a  of  the  aorta  was  fattv    tZP         '      '''°''''  '"  ««^"'--    The 
and  a-dematous  at  the  bases  "  ^°^'  '""■'  voluminous,  congested 


iitf! 


r 


i 


W 


(Ly^L.  ii\ 


IV.— NOTES  ON  SPECIAT.  FEATURES,  SYMPTOxMS 
AND  COMPLICATIONS. 

by  william  osler,  m.  d. 

1.— Analysis  of  tuk  General  Symptoms. 

(/.  Tke  Ra.-th. — Rose  spots  were  noted  in  199  cases,  8G.9  per  cent. 
In  nine  cases  they  were  very  abundant,  occurring  not  only  on  tlir 
trunk,  but  on  the  arms  and  thighs.  In  one  instance,  a  lad  of  14,  they 
were  present  on  the  face. 

In  two  instances  there  were  small  petechial  spots.  In  one  of  the 
cases  (IIos.  No.  469)  the  attack  was  very  severe,  and  the  patient 
died.     In  one  of  the  fatal  cases  there  were  extensive  ecchymoses. 

A  diffuse  erythema,  usually  punctiforni,  and  in  m.ost  instancts 
about  the  thorax  and  abdomen,  was  noted  in  seven  cases.  Iv  was 
present  usually  at  the  time  or  shortly  after  admission,  and  disappeared 
in  all  instances  within  two  or  three  days.  In  one  case  it  was  also 
on  the  arms  and  about  the  joints  (168). 

In  one  case,  a  boy  of  eight,  there  was  an  urticarial  rash  on  the  face. 

Peliomata— tachcs  bleuatres  or  maculse  ceruleie — were  noted  in 
several  instances,  always  in  association  with  pediculi. 

h.  The  Fever. — The  temperature  was  taken  every  two  hours  in  tlie 
rectum,  unless  there  was  special  reason  against  it. 

In  hospital  practice  there  are  but  few  opportunities  of  studvini; 
the  fever  of  onset.  There  were  two  instances  in  which,  contrary  to 
the  general  rule,  the  temperature  reached  the  fastigium  on  the  seoond 
day.  One  is  the  interesting  case,  to  be  given  under  the  section  of 
"typhoid  fever  and  malaria,"  in  which  within  24  hours,  from  4  p.  m, 
on  the  22nd  of  October  to  4  p.  m.  on  the  23rd,  the  tempcratiu-e  rose 
eight  degrees,  and  then  remained  high.  The  other  instance  illustrate? 
how  abrujjtly  the  temperature  may  rise  at  the  starting-point  of  ;i 
relapse.  In  No.  3684,  after  seven  days'  apyrexia,  the  toniperature 
rose  more  than  seven  degrees  in  36  hours.  This  was  the  starting- 
point  of  a  relapse,  and  the  temperature  did  not  reach  normal  again 
for  fifteen  days.     An  instance  in  which  a  gradual  step-like  ascent 


51] 


SYMPTOMS 


■"""'"'  *"""'■  'Wc™,  una  a.,.p,u„uo„.. 


-  51 

of  the  tempornture  occurred  ,1.,.^  i      7 

4710),  a  case  .ulmitted  for  Z.f   Z  "r  '?  t""  ''•  <«-•  ^o. 
'-- after  thirteen  days' sta,!:   1.;:     ^^'"^''  ''"'^'"P^d    typhoid 
I  here  were  152  cases   G(i  'i 

the  <l^e..e  the  thern.o„;te;;^:ter;^"it o'^'^f  "'  ''""  *'"^  ^^-"'^ 
-  y  J.ad  temperature  ul.ove  W      „         "T'  •'"•^''-     '^^-'^'''t  cases 
Fi/ty-ni„e  cases  had  a  teni.,m..,f    '    V         '      ''  '"^^'^'''^^'r  ^^as  107° 
.■igl.ty-fivecasesha,la    eL^':^,^^^^^^  .'^^^^-^'"^   ^«^°  «nd  10G°,  and 
85  cases  with  a  temper  it^ri  '''''"'  ^^^^  '""'  105".    6f  t  e 

"-tl.M.2percen;:'^:Th  59  r  ' 'w  ""'  ^^'^^  ^'^^  -- 
105°an,l  106°  there  were  10  de X  iT  <  '  '  '^"^^'"^"^^  ^^^-e" 
'■ases  w.th  a  ten>pcrature  above  106o  f  '"'  '"''''  '-^"^  «^  ^''e  8 
-^-  There  was  only  one  fata  cas^Mvith  Tt  ""'  '  '"^''^''  ^^^  P- 
''  n-n  a^-ed  70,  who  was  admittc  .  T^l  7'7^^"-  '-'o-  104", 
<n"sol.dat.on  of  the  left  lower  lobe  and  ^  '''""'  ''''^'''^^•'  ^^''^'' 
"I  pneumonia.  '  "*""  ^^'-^  <^'«sc  was  regarded  as  one 

('.  Puke. — There  woro  <»? 

^fe  K>iiowing  is  the  ::t;:^  :?inl:  r'"  r^^  ^^ '''  --^  -- 

10oases,of  whichTdied;   150-160   5  '\"'''  ''^'^  =  ^''ove  160, 

;:^^;  J5  cases,  of  which  5  died  130  iT',  "'"''  '  '^'"^^  l^O-' 
'':;  ;  120-130,  52  cases,  of  wh  d.  fdi  ^  '^  "^^«'  ^'  -'>-^  none 
«'th  the  pulse  rate  belo^v  1  '^0     T>.  ''"^  '''''■'  ''"^  f'^t-'l  case 

|-nce  very  slow  pulse,  on: at  4     calem!""?'''  k""'"^'^  ^«'^-- 
1 12j  per  minute.  ^    ^  ^ ^^^' '""'  another  at  56  (case 

''•  I >i(irrh(m. —The  l)oweIs 
-t.    Of  these,  in  28  the  disclZ,  ";;:. '"  "''>'  ''.''^^^>  33.2  per 
''^■^'-^'•f-     In  153  cases  there  wis  1    ,       u'^'""''  "'  ^^'  "^«^l«rate 
'^^ ''"-'«  ■•"  the  fatal  cases  wa  t  folio    """     ''''  ^«"^'^-n  «f 
--^'•Vht,  in  10  it  was  proC  and     T!-  '"  '  """'^  ''''  ^^'-^^-a 

''•  ^/^/m,._The  organ  was  enh"  1=  '"'  ^^'"'^  "'^  ^^^"'hcea. 

'^-ostal  margin  in  147  Jates         '^'^  "'^^'-^^^^  *«  be  felt  beneath 


- — Relapse. 
In  the  229  cases  there  were  TS 

'*>  fever  «„„ed  a„d  |,orsistaI  J  !,„/;,         ° '"'''""'  "f  •■'l'."e.via, 
"'»»'  more  |.ro.n„e„,  „3.„,,,„;;  '  7" '"'"  »  "™'--,  a,>d  i„  ,,,,,„,,' 

"*■ '»'-.'«;  ^piee„,  „.  u:„T.::.i;;.:,t:;:„r "-«.  -  the 


in 


\ 


I 


Hi 


•  ! 


'. 


^  \.^. 


62 


Willitiiii   Onler. 


•■).' 


The  iiatiiri-  of  the  relapse  in  tyjihoid  fever  remains  obscure.  W, 
spealv  of  a  fresh  invasion  of  the  bacilli,  u  iresh  formation  of  tli, 
toxins,  but  whv  the  disease  should  start  afresh  after  a  wkK- 
convalescence,  aiid  perhni's  pursue  a  more  severe  course  than  in  tli. 
original  attack,  or  why  in  some  cases  there  should  l)e  a  second  ,„ 
even  a  third  repetition,  nvc  remain  completely  ignorant.  We  d(,  imi 
even  know  whether  the  incidence  depends  on  endemic  intluencfs  i;,. 
would  appear  from  the  great  variation  in  the  freciuency  of  rclnpse  in 
different  places),  on  influences  which  affecahc  fie^-r/ ;  or  on  peculiariti.- 
in  the  individual  organism,  influences  which  affect  theso/7,exha.iM.  I 
quickly  by  the  first  crop,  but  renewed  r..=^  quickl.v,  and  again  reiidcr/M 
susceptible.  The  first  attack  gives,  as  a  rule,  that  intiiiii.tc  nii.i 
remarkable  modification  of  the  tissues,  fluid  and  solid,  which  wee;,!! 
immunity;  but,  failing  this,  however  produced  (weakness  of  the  arni.v 
of  phagoctves?  f\vilure  of  the  development  of  the  antitoxins/i  th, 
organism  is  again  liable  to  infection.  On  any  .  lew  it  is  diflicilt  f 
understand  why  indiscretions  in  diet  should  sometimes  precipitiito  ;i 

relapse. 

There  were  no  relapses  in  the  first  33  cases  treated  on  the  symp- 
tomatic plan.  In  the  196  cases  treated  ^ince  the  introduction  of  i\v 
cold-bath  treatment  there  were  18  definite  relapses,  9.2  per  cent.  Tl.c 
dfts  of  apvrexia  were  as  follows  :  12,  3,  5,  10,  4,  7,  6. 

All  of  tiie  cases  of  relapse  were  bathed.     Four  cases  died. 

We  cannot  follow  accurately  the  rule  of  calling  nothing  a  relaiiM 
without  a  definite  period  of  a])yrexia.  In  rectal  temperatures  tlie 
normal  limit  must  be  placed  at  about  99° ;  and  after  the  declin..  n. 
the  original  attack,  a  period  of  some  days  with  a  teniporatuiv 
between" 98°  and  99.5°  should  be  regarded,  i)articularly  in  a  voiiii-- 
person,  as  an  interval  sufficiently  definite.  Thus  Ada  P..  (IIos.  Xn 
5430)  was  admitted  about  the  10th  day  with  a  severe  attack.  I.y 
the  20th  day  th^  temperature  had  fallen  to  99°,  then  on  tl.c  21st. 
22nd  23rd  and  24th  davs  the  temperature  was  between  99'  and  100  . 
occasionally  falling  to  98°,  and  twice  in  these  four  days  nsn.- 
above  100°.  Then  on  the  24th,  25th,  26th,  27th  and  28th  days  tliere 
was  a  gradual  ascent  and  the  temperature  reached  102  5°.  On 
the  28th  it  reached  104.5°.  The  spleen  enlarged  and  ^hcre  «:,- 
a  crop  of  rose  spots,  and  it  was  not  until  the  35th  day  that  the  te.- 
perature  reached  normal. 


.^3] 


•V/a/  FmUur.,  S,„njAon,,  and  Coo.pfications. 


.Iw.'  i.  a  n„rte,.  „,,,„.,,„e»  „r  .„  .Ik   S,      ,        , ^  i' "'i;  "'  T 

iHiH„„,.  A,,.::;:^;:;:;;/;'':7^■:t;:r;::^t;'''■T" 

»»r.v  2n,l,  tl,,:  te,„,„.rature  f„r  ,l„.  r.J  ""-,"""  '".  ■<""■ 

-'.> -ird  she  ,„„l  „  ol,i„,  i„  „,.w,  .,,„  ,e,,!„I  .  »„„.  .„'  ™::",;'""- 
-s  between  lokn^l  lo/o"    tT"'  r'  ^''^  ''''  ^''"  ^-M-ature 

I,™. ,       Tl,e„    „„  ,^  "",■'"''  ""    """"gl"   cmv-alcsceiice    w„s 

•b""""^-      men,  on  the  aiternoon  »if  tl».  ii.i.  ^ 
rose  to  104°,  and  by  ,nidnid.t  to  iX  ll  !       temperature 

» -.  .ash,  „„„  .he  'de  \^:;:t;tt:  ir''"''';''V'"'' 

-lirt.i..g  ..r.hedisease,  I ,„.  fr.„, 'la  ,  ,"y   td  1 ,       Z  7      >  ',  " 
I.  .e„„o,l  a  eontal  J  ,  "t,    ;e^    rallT'™"'  "'"•  T"'''  ""' 


Ui  V. 


ill; 


It 


Ih 


>  I 


51 


Wi/liiiin    Oxhr. 


[fH 


101^.  All  tlie  sytnptoniH  improved  and  Im  lookod  sih  if  howns  ciifcr 
iiig  upon  iiip  convalescence.  Then  on  tlio  Kltli,  17th  and  IHth  tin 
temperature  was  between  9fl"  and  100",  and  on  the  19th  day  rose  t.. 
103°.  The  spleen  enlarf^ed  and  there  were  roHO  s|»ot8.  Tlie  seediiij 
attack  lasted  lor  only  ei;j,ht  days,  the  fever  p-adually  suhsidini;'. 

It  is  iiii|)ossil)le  to  draw  a  hard-and-fast  line  between  tiieseeasi.. 
and  the  }j;enuine  relapse.  This  is  well  illustrated  by  the  follo\\iim 
oases  : 

Annie  M.,  ajred  28  i  Hos.  Xo.  looG),  admitted  aimut  the  eij:lit[i 
day  of  a  very  severe  primary  attack.  On  the  morniui;'  of  the  Utlli 
day  the  temperature  touched  98",  then  on  the  25th,  2(Jth  and  27tli  ii 
ranged  from  100"  to  104°,  on  the  28th  day  it  attain  reached  ncurl'. 
9,S°,  but  on  the  29th,  30th  and  31st  there  were  no  marked  (b(>|is 
and  the  teni])erature  was  between  101"  and  103".  About  the  .'Jlst 
day  the  temperature  began  to  rise,  and  she  entered  ii])on  ii  period 
in  which  the  evening  rise  was  up  to  and  above  104°.  There  wen 
rose  spots  which  came  out  in  crops,  and  this  recurrence  foriiiwl  a 
very  severe  attack.  Kven  with  the  sponging,  Ixstween  the  31st  ;mil 
43rd  day,  the  temperature  did  not  sink  below  101°.  Trom  the  4otli 
day  the  temperature  was  lower.  She  gradually  sank  and  dieil  on 
the  49th  day.  Here  was  a  case  in  which  it  was  impossible  tosaytli(rc 
had  been  any  interru])tion  in  the  pyrexia  for  more  tjian  an  hour  or 
so  at  a  time,  but  taking  the  symptoms  as  a  whoU ,  there  can  Ix'  no 
question  that  she  had  a  very  definite  and  positive  rela|)se. 

Mary  :\IeG.,  aged  13  (Hos.  No.  6405),  admitted  with  fever  which 
began  two  weeks  ago  with  severe  headaches.  For  the  first  hi  days 
in  hospital  there  \\:i-  scarcely  a  day  in  whi  ii  the  temj)eratureilid  not 
rise  to  105*^,  and  once  rose  to  nearly  10G°.  The  baths  and  spoiigings 
had  very  little  influence.  On  Decend)er  ItJth  and  17th  the  tempcratniv 
became  a  little  more  irregular,  and  from  the  17th  to  the.'iOtli,  nearly 
two  weeks,  there  was  a  remittent  type  of  fever,  the  temperature  fall- 
ing each  day  to  the  neighborhood  of  100°  and  then  rising  in  the 
evening  to  103°  or  104°.  These  remissions  were  very  marked  on  Dt- 
cember  24th,  25th,  2()th  and  27th,  when  the  evening  teiiijM'ratiirosank 
on  each  day  to  99°.  Then  on  the  28th,  29th,  30tli  and  31st  the  niornins; 
remissions  were  not  so  marke<l,  and  the  evening  exacerbations  were 
a  little  higher,  reaching  104°.  On  the  42nd  and  43rd  days  of  her  iiine?- 
the  fever  became  more  continuous,  and  from  January  1st  to  tlic  9tii 
she  had  fever  from  103°  to  105°,  with  very  slight  remissions.    Th' 


5f)] 


H  if  ho  was  ciitcr- 
tli  and  IHtli  rhr 
liltli  (lay  roHc  u, 
its.  TIk'  hccoikI 
y  Huhsiiliiii;. 

WCOn     tllCSC  r;lS(  « 

by  tlici  follow  ill:: 

iltoiit  the  t'i'jriitii 
niiiii'  of  tli<!  null 
2i;tli  and  '27tli  ii 
II  rcaclu'd  iicurlv 

0  marked  (lr(i|i- 
AI)out  the  ;51>t 

d  u|)oii  a  pcrioil 
4°.  Tlion,.  wciv 
irrcnro  fornicd  a 
ct'ii  th(!  .'51st  ;iii(l 
From  the  -lotli 
ink  and  died  on 
^sible  to  saytlicrc 
than  an  lioiir  nr 
there  can  lie  im 
'lapse. 

with  fever  which 
the  first  I'Ulavf 
iperatiire<li(l  iidt 
lis  and  spoiigiDgs 

1  the  tenipcratiirt 
1  the  ;5()th,  nearly 
teinperatiirc  fall- 
len  risintr  in  the 
•y  marked  on  Dt- 
teni|M'ratiiresaiik 
31st  the  luoniiDi; 
:acerbations  were 
hiysof  herillnes* 
iry  1st  to  tlic9tli 
■emissions.    The 


■''''*'"•'''■''"•  %»Wo»M  „,,,,  r„,,,,,,;,,,,,,,„^ 


"<'-an  interval  of  .na  k      r    .hu:  "       I?""'  ""'  "'"'''-''  ^''-- 
^"■"  1-rio.ls  of  e.,„ti,„.,.<l  fever      "•   '"  ''"  '^''"'-'•''t-re  separated 

A  protracted  (ever  mav  (h.v,.I,u    • 
""-'"ia  and  nu.st  not  betaken      '  ''Lr'"'^'''''''"'''  '"'•''  I'^^'-^ypl'oid 
i^-  2132).  the  patient  ha;        et  r    "  rr'-  ,"/'":  «"^^'  "^'  ^-'»  0. 
P-'^-T,.  ran,in.  between  105^^^      O        "''''  ''"''^'^  "'"  ^'"^^ 
1-en-.  beoan,  and  for  four  d        t  !     "  ""'  "'"'  ''"•^'  -"^■- 

^8°;  then,  between  Decend.er  td^.n^^oTf^''"'''''''''''  ^^  «* 
<""«tantly  between  99.6^  ami  101-  r  .  .  '  *""M«'r"ture  was 
'"•••«'»ia  (the  ease  is  referred  to  „„"  J,,.!  Ii  '  '!"''''''"'  ''  l"-«'<'-nd 
"•"«n'iu);  and  tho.,>,d.  the  snleen  J         ,        T''""  ""  l"'«t-tvphoid 

:-  ...od.  and  it  .;.s,  r^u!- ;  "v ;  ::^j:;  "7--  -...ii.i<>n 

instance  of  relapse.     From    r.         \         '  "-^ '  ""'  '"'Wrch-d  as  .i,, 

»  iicic  were  i|i,  . ,  ,,fg_ 

During  convalescence  there  ,..«,-  i 
intervals.     There  were  ei' h.       ,  ^r  "^."^".^.r^'^  ^--  ^or  short 
normal    temperature,   the    CL  C:m;"    v'     ' '^'^ '^  ^'^"'^^  «^ 
""""'alH-.s  Of  convale.,..„,e  m„sf  ,  V  ,,    ""^"^    temperature 

"•-<'  so-called   ree,         ...^ee"  1  !?':' :\  ^''"^'-^-'^'-'d  '.•om 

■"'Portant  to  recogui/e  the  fio.  ./  /l^'^-^^'I'^^'d    elevations.      It  is 

-vous  subjects,' the  aL^^^^T  '"  •"'"''  ''"''''"»'  ^'^^  '»  -- 

n'-^locted,  and  when  strong  ""^^.1^  ^""'-"^  ''"^""*''^''  '^'^  '--}'  '-e 
"I'-  Though  really  of  n  n  Z'\  ''  '^^  d  V  ""''  '^  ^''""  ^'^  ^°^-* 
no  little  anxiety  to  the  phvsthn    ',  uT''  '"">'  ^''  '^'  «"»««  of 

'''ready  been  referred  to  L  count  I  'u'  '"  ««»^-^^'^'«-™ee  has 
='->•  1<-'P  up  a  slight  fever  11;  f  '\'  "'""""  ^-'•'^' *««> 
«'■  complications  and  se.,ul  th  ' ,  "''  ""^  independent 

-'1  -derstood  elevations  of  l^rZ^T  ""  "'^  -''''''''''^' 


56 


William  Osier. 


[56 


relapse.  The  following  are  brief  notes  of  the  eighteen  cases  in 
which,  after  the  establishment  of  normal  evening  temperature, 
irregular  elevations  occurred : 

Case  I. — Henry  H.  (Hos.  No.  392) ;  mild  case,  afebrile  on  the  23r(j 
day.  Ten  days  subsequently  the  temperature  rose  to  101°,  and 
remained  between  99°  and  nearly  101°  for  36  hours.  He  had  had 
solid  food  on  the  7th.  He  had  been  constipated  for  five  days. 
With  the  return  of  the  fever  there  were  no  special  symptoms. 

Case  //.—Charles  S.,  admitted  June  7,  1891  (Hos.  No.  3244). 
A  very  protracted  and  severe  attack.  The  decline  in  the  fever  was 
very  slow,  and  it  really  was  not  until  the  50th  day  that  the  teminr- 
ature  was  normal ;  then,  every  day  or  two  he  had  an  evening  ri.-o  to 
100°  or  101°.  From  the  61st  to  the  67th  day  the  temperature  was 
normal ;  then  from  the  67th  to  the  75th  day  thp  temperature  rose 
every  afternoon,  and  on  the  71st,  72nd  and  73rd  reached  nearly  103. 
There  was  nothing  apparently  in  his  condition  to  account  for  this 
rise  in  temperature.  He  was  at  times  constipated,  but  it  was  never 
very  clear  upon  what  fever  depended.  He  ultimately  made  a  satis- 
factory convalescence  and  was  discharged  from  the  hospital  on  the 
79th  day. 

Case  III— A.  G.  (Hos.  No.  3260),  admitted  on  the  12th  day  of 
a  mild  attack.  The  temperature  was  normal  on  the  21st  day.  Then 
from  the  23rd  to  the  29th  day  the  temperature  range  was  from  97'  to 
99.5°.  On  the  30th,  31st  and  32nd  the  temperature  rose  to  between 
101°  and  102.5°.  On  the  37th  day  the  temperature  rose  to  102°  and 
remained  elevated  for  12  hours,  then  became  normal  and  remained 
so.  There  was  nothing  in  the  condition  to  account  for  this  subse- 
quent rise. 

Case  IV.— Vim.  S.,  aged  24  (Hos.  No.  3552),  admitted  on  the 
7th  day  of  a  moderately  severe  attack  ;  temperature  range  from  103" 
to  104.5.°  On  the  21st  day  the  temperature  was  normal  and  did 
not  rise  above  98.5°  until  the  evening  of  the  26th  day,  when  it  Ijonan 
to  rise  and  on  the  27th  day  was  103.3°.  The  edge  of  the  .'^pleen 
could  be  felt,  and  as  there  were  a  couple  of  doubtful  rose  spots,  we 
began  the  baths  again.  A  relapse  seemed  ])robable,  but  on  the  'iSth 
day  the  temperature  fell  and  was  99.5°  in  the  morning.  From  the 
28th  to  the  43rd  day  he  seemed  perfectly  well  and  lie  gained  in 
weight.  Then  on  the  43rd  day,  18  days  from  the  ])revious  elevation, 
the  temperature  rose  rapidly  in  the  morning  to  105.5°.     There  were 


57] 


'V«^«^  Fe.U.e,  Sy..,to..  an,.  c:o.,n.aUons. 


%  between  101°  and  102o.     O  "ZT.  7'.  '"'"'''"^^  ^"  ^^^^  ^-i"' 
Has  normal  from  the  46th  to  his    i  oh-.t  V "  '''^'  ^''"'^^"^"-V,  and 

^00,  It  was  impossible  to  attritt     h     ?'  T  '''"'  ''''  ^''^>'-      ^ere, 
■'special  constipation.  ^'''^  "'^  ^"  '-^"r  error  in  diet  or  to 

normal  on  the  27th  and  28th\hv.     n  ^^^    .  ^^''"P^rature  was 

the  -^Oth  it  rose  to  105°,  an  on  L  .?'  ''"'  '''^  '*  >•"««  ^o  103°,  on 
to  i'or  discharge  it  rem'airir  1^"  Th'''"' -•  ''''"^  ''^  ^^^^ 
"»<'   nervous,   and   very  oonstinnllj       rr  ^'^*''"*  "««  e^^eitable 

to  105°  after  the  temp  rat      'Ht  '''"   "'"'"    ''^"'^^''" 

than  a  week  and  had  'been  norm'     '"V""!'""^'  '^"'"^  ^^  "-- 
--  complication,  but  nothing    :^^  fo  undt        "'  ""'^'  "^  ''^^J-^ 

21st,  on  the  8th  da,  of  a  ^^t^r!^;^''-  'J!''^'  -'-^^^d  October 
nornml  on  the  24th  day  and  rem-n';  d  '  ^^'^''"''^^•'^^"r^'  beached 
--  to  103°  and  ren.ain.l  betw  Jooo  ::;,"  It'''''  '''^'  ^^•'-»  '^ 
■ng  morning.     Looking  for  the  n  „b  r.  ^^    ""^''  ^^^  tbllow- 

absccsses  were  fo„„d  on'the  b  el  'if'  "'!"'  '"'  ^^"■^'  ^-'  -'="' 
;-eted ,;  he  did  not  gain  streng     ;,,,":  "'"r^'^''^^^  "««  very  p,,,- 
-''  the  81st  to  83rd  days  fronf  1  e      '  ' '/  "^^ '''  •^— >'  l«t,  2nd  and 

"a ''"'7; !!' °  "'^'""^  -'^  --"         ' '""'''""' "" '^'"'"'•'^- 

'-^th,^th^:h  t'lf  :^nd  ?  ?""•  ''"•  ''''^'  ^''-tted  Octo- 
'•"  to  normal  on  the  •25[h  d  ^  On'';;'"''' '^"'"'^  ^  ^^'"^--ture 
'^"'I'orature  rose  to  102°,  and  ker^nn  7'''"'"^^  '^  *^'^  -^^th  the 
obvious  cause.  He  had  n^t  hid  so  ,7  ?'  "'-''  '^""y  ^^''thout  any 
;'o«',  and  on  the  47th,  48  h  a^;^  49'    "';    "^'^  -"-'J-cence  wa 

'"-'  the  teniperature'rea    „•  :  103°  -If  ''!  'r'  '^  "^^"^'  ''^^^-'^- <>^ 
"•as  established.  ^    ""^  ^  •''^^''  "''.ch  the  convalescence 

^^^^^^2™;;;?;:^::.^-;:^^  Xo.  4452,  admitted  De- 

^t-e  not  tailing  to  norn.a/.^  n  r"  5;r?"'"'  T"^'  '^'  ^^I- 
:  ""•'-^-  "»J  ''ad  hysterical  attacks  V  f  l?'  .  ^^'  '^'^'^^'^'-^d  ^ery 
!ye,nporature  ranged  from  osf^rino""^'''  '''''  ^^'  the  15th 
'■f-ated  and  he  complain  d       "L  a      '  '. ''^  ^«"^-  --  - 

''^'^^•^'^'-^•onthebaAandabllr:^.^^^ 

«re  a  tew  suggestive 


■4 


f 


I 


IN,-. 


58 


William    O.'^kr. 


[OS 


spots.  On  tlic  iii-iht  of  the  14tli  he  was  ulso  delirious.  We  thouglit 
that  it  was  possibly  a  very  late  relapse,  but  the  temperature  fell  and 
on  the  18th  day  was  normal.  He  had  not  been  constipated,  and 
at  the  time  of  the  fever  he  had  been  having  solid  food  for  between 
two  and  three  weeks. 

CWe  7A'.— Louis  M.,  aged  17  (Hos.  No.  4458),  admitted  on  tli( 
10th  day  of  an  attack  of  moderate  severity.  The  temperature  on  the 
20th  day  was  normal.  From  the  20tli  to  the  30th  day  the  temper- 
ature range  was  from  97°  to  99°.  From  the  17th  of  January,  tlie 
30th  day,  to  the  2nd  of  February  there  was  mild  fever,  the  temper- 
ature rising  every  day  to  100°-101°,  without  complications  or  un- 
favorable symi)toms,  and  it  seemed  an  instance  of  protracted  i)ost- 
typhoid  fever  rather  than  a  definite  relajise.  He  was  not  constii)!Ued  ; 
he  sat  uj)  February  7th  and  made  a  good  convalescence. 

Cv,sc  A'.— George  P.,  aged  21  (Hos.  No.  5737),  adhiitted  on  the 
8th  day  of  a  severe  attack.  Tlie  temperature  fell  gradually,  and  was 
normal  from  the  31st  to  the  50th  day,  when  without  any  ol)vi(.us 
cause  it  rose  on  the  51st,  52nd  and  53rd  days  to  100°  and  102°.  The 
tongue  was  slightly  furred  ;  the  spleen  not  enlarged.  There  was  no 
consti])ation. 

Case  A'/.— David  Martin  (Hos.  No.  5900),  a  very  protraek-d  (•a^^e, 
in  which  the  temperature  did  not  fell  to  normal  until  the  33rd  day. 
The  patient  was  febrile  from  the  45th  to  the  52nd  day,  due  apparently 
to  a  phlebitis  of  the  left  femoral. 

Case  A/J.— Wm.  W.,  aged  23  (Hos.  No.  5937);  case  of  modenite 
severity.  Temperature  normal  on  the  loth  day.  From  the  2oth  to 
tlie  28th  day  tlie  temperature  rr>nged  from  99°  to  101°.  This  occurred 
when  he  was  up  and  about  the  ward,  and  did  not  disturb  the  con- 

V'licSCCllCC 

'  Case  A7//.— Minnie  — ,  aged  22  (Hos.  No.  5995),  admitted 
September  29,  1892,  a))parently  late  in  the  disease.  The  teiiipw- 
ature  Wi>s  irregular  and  fell  to  normal  October  9th.  From  October 
19th  to  27tti  the  temperature  rose  once  to  104°  and  every  day  to 
nearly  103°.  She  had  one  or  two  sweats;  the  abdomen  was  Hat,  not 
sensitive,  no  spots,  tongue  perfectly  clean  ;  bowels  regular.  Conva- 
lescence undisturbed. 

In  very  protracted  cases  the  convalescence  h  often  slowly  cstuli- 
lished,  and  the  temi)erature  may  be  normal  lor  a  day  or  two  and 
then  slight  elevations  will  occur  for  four  or  live  days  without  any 
special  significance,  thus : 


59] 


%o.W  Features,  ,y>n,to..  and  Co.pl,.aUons. 


Case  ATF— Cliri 


attack  of  great  severitv,  and  fro 
temperature  had  been'  fall 


^eyer,  aged  52  (Hos.  N 


-o.    6095),  had 
'»  the  43rd  day  to  the  53.^  d 


59 


an 


101°.     Then  from  the  53rd 


the  58th  to  the  70th  there 


"g  gradually  and 
to  the  59th  dav 


ra 


!iy  the 
"giiif^-  from  98°  to 


without  any 
slight  fev 


vr  w 


aggr 

dissociated  witl 


was  every  day  a  rise  of  fr 


It  was  normal.     ]i 


roni 


'ation  of  the  gen 


'"ni  2°  to  2.5° 


:^::5!^^'"-«-ged28rS 


general  symptoms.     Possibly  thi 
crop  of  boils. 


I-  30th,  1892,  with  an'att  k  of  mod  ""^  '"''^'  ^^^™'^^^^  Octo- 
perature  was  normal  bv  ^"venLt  ""•"''  '"'  '"  ^^^'"- 
parotitis.  On  November'  25th  2«th  n.]  97/."  T^""  "^"  ^  "'•^•^^^^te 
•■ally  rose  reaching  103°,  and 'fell  iCu^Vlll^"''Tl''''  ^"^^■ 
iibdommal  symptoms.  '^       '^  "^^''  ^"<1  29th.     No 

Case   XrZ— Charlr.s    H      no-eri    ir    /tr         . 
November  lOtl.    ^^'-2,  on  d,;  Stl,  d.        rf  ^^  """    ''''^'  ^"^"''"^^ 
•'>•  ^''«  ^Oth  d  ,;  the  21st  tJ.!i  ;  ^"^P-'-^^ture  was  normal 

^eil  to  norma..      .,,„  „„  t     '   7     "tr  30?.^^  '''"'  '^"^  ^"^"  '* 
"MS  between  99°  and  101°  witho  t  I       '^'  temperature  range 

the  28th  temperature  rose  o  1 0?°  tZl  Zl  '"  ''"'  ''''''  ^"^  «" 
2!)th  kept  above  101°.  It  ml  '^  '^f  '  '"^"^  ^i»-o»gl>o«t  the 
'H'tween  99°  and  100°  for  sev  ru  "d^  •'  T  '^''  ^^'^''  ^»*  remained 
;-  a  relapse,  but  no  spots  were  leen  ,L  tf  ''T  "'  ^''''  '^""^''^*  *" 
Ti.  pati.t  had  a  4  .narked  S;:^;!^-^^^-"  was  not  palpable. 

<'.M    'V  I  777.— John    F.,   asred    90    /Tt        xt 
October  10,  1892,  on  the  15th  r    f      ^  ^"^    ^^^^^'   ^'^mitted 

-«'>•  '■'.'.  ;-er.  On  tlle^U^  ?,  ^ 38^ d^tf^'  ^^-^^^  '""^'- 
"'IS  nornml;  then  on  the  39th  40fh  or  n  ,  ''  *''"  ^^'"Perature 
«-"  10^^^  to  103°,  and  it  w^i.ot  '.t  I'^I  ,f  ,  ''^^'  -".^e  .vas 
""■re  was  again  norn.al.     There  we  '  f         '' '''"'  ^'^^  ^^^'"P^'^- 

•^P'-"  was  not  palpable,  and  Ire  w.  "''  ■'•''"''^""^'^  '  ^^e 

constipated.  "'"^  ^"^^«  ^^^''^Mio  rose  spots.     He  was  not 

-ogi^;i:nS^Sr  ir?— --'-^  o-'e.nite 


■•I  I 


\f  I 


m 


i 


\%, 


60 


Wifliam  Osier. 


[60 


returns  f  r  the  city  of  Baltimore  for  1892  there  were  33  cases  imdor 
the  head  ng  typho-malarial  fever.  We  have  had  very  good  oppor- 
tunity of  studying  the  relations  of  the  two  diseases,  as  there  have 
been  under  treatment  in  the  medical  department  about  500  cases  of 
malarial  fever  during  the  time  in  which  the  229  cases  of  typhoid 
fever  were  admitted.  _ 

We  do  not  profess  always  to  be  able  to  distinguish  in  their  early 

stages  cases  of  malarial  fever  from  cases  of  typhoid  fever.     So  much 

alike  are  they  that  frequently  patients  have  been  sent  to  the  wards 

from  the  dispensarj  and  have  had  their  heads  shaved  and  the  bath 

treatment  ordered.     The  routine  order  in  all  fever  cases  is  to  have 

careful  ai.d  repeated  examinations  of  the  blood  during  the  first  tw.. 

days.     If  Laveran's  organisms  are   absent,  malaria   is    definitely 

excluded.     To  mistake  typhoid  fever  for  malaria  is  much  less  rare 

than  to  regard  a  case  of  remittent  as  one  of  typhoid.     There  was  no 

case  with  the  characters  of  the  two  diseases  so  blended  that  it  seemed 

a  com  ound  or  hybrid  malady,  nor  was  there  an  instance  m  wliidi 

the  manifestations  of  the  two  diseases  were  concurrent.     Very  nuiny 

patients  with  typhoid  and  malarial  fever  were  admitted  from  the 

same  low-lying  sections  of  the  city  and  the  suburbs,  districts  in 

which  both  diseases  prevail  extensively  in  the  autumn,  so  that  it 

would  have  been  strange  not  to  have  met  with  some  cases  of  tho 

combined  infection. 

in  three  cases  there  was  a  definite  history  of  malaria  within  a  tew 
months  of  the  onset  of  the  typhoid  fever.     Martin  M.  (Hon.  No. 
4027),  admitted  October  12th,  1891,  had  had,  three  weeks  before  h.sl 
admission,  chills  every  other  day  for  a  week ;  then  the  next  week  or 
every  day,  followed  in  each  instance  by  fever  and  sweating.     Subse- 
quently the  bowels  became  loose,  and  on  admission  he  had  a  con-l 
tinuous  pyrexia  between  104^  and  106°.     The  blood  was  negative.! 
It  was  noted   tho  second  day  after  admission :   "  This  case  is  oil 
interest,  coming  from  Sparrow's  Point.     He  had  been  exposed  to 
malaria,  and   probably  had  three  weeks  ago  genuine  internutten 
fever ;  he  has  had  no  sweats  and  no  chills  since  admission."  j 

The  disease  ran  an  ordinary  course,  the  fever  presented  nothnij 
uncommon,  the  temperature  gradually  declined,  and  he  made  a  sati^ 
factory  convalescence.  ,  ^     , 

A  second  case,  Richard  B.  (Hos.  No.  4083),  admitted  Octobe 
1st,  1891.    A  month  before  admission  had  had  for  a  week  teitiaj 


so.asBai 


28.S4.i4\ 


t H 


LJ 


33  cases  under 
ry  good  oppor- 
as  there  have 
lit  500  cases  of 
ses  of  typhoi( 

in  their  early 
ver.  So  mucl 
t  to  the  wards 
jd  and  the  batli 
eases  is  to  have 
ng  the  first  two 
a  is  definitely 
much  less  rare 

There  was  no 
i  that  it  seemed 
stance  in  which 
it.  Very  nuuiy 
iiitted  from  the 
rbs,  districts  in 
umn,  so  that  it 
me  cases  of  the 

ria  within  a  few 
1  M.  (Hos.  No. 
weeks  before  iiis 
;he  next  week  oii 
k-eating.     SubM- 
1  he  had  a  con- 
id  was  negative 
This  case  is  o 
been  exposed  ti 
line  intermitten 
lission." 
resented  nothin 
ho  made  a  s^ati 

.dmitted  Oetobi 
>r  a  week  tertia 


Xo  40^1.     ±rim^.__  .^t::u-^^y  Admitted.    (£J/  /6'^9l 


r 


Tpin[) 


Ri^si 


Stools 


Urine 
Dav  .)! 


!6  iS: 


7f)  70 


S2  64- 


16  20. 


■60 


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Chart  111  Case  of  combined  Malarial  and  Typhoid  infection. 


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32'      '■.23*      :38*       2a'.i0:24'-2e:2a'.Z4.24  24  28  24\2B:      '.sa'       ■ZB\20\3i'^32.3e'2B\38*2i..24'l8\ 


f6) 


J L 


i      i 


(1) 


(9) 


ill] 


iiiterniittcn 

'iirtlier  chil 

(ntioii.     J] 

actively  do] 

'i'vor  ran  a 

11"  chills;  t 

liis  case  to  c 

!"■  'lad  had  i 

A  third  ( 

November  4i 

year  he  had  i 

cine.     He  hii 

month  hefure 

irregular  fev« 

rose  spots,  no 

in  any  way  si 

The  /bllowi 

with  malaria, 

''lood,  subseqi 

''fred  20,  had, 

t'oiigh,   occasi( 

October  16th,  ( 

"Ifhe  17th  to 

'■"  the  blood. 

day.     On   the 

a.  111.,  and  at  3 

rose  to  nearly 

"wmal  at  8  a'  i 

and  the  quinine 

22nd  the  tempei 

pcratiire  had  be( 

grains  of  quiniii 

liad  disaj)peared 

ature  was  97.5°. 

the  evening,  and 

it  was  102.2°,  ro 

^05°:sothatwi( 

on  the  23rd  the 

this  was  a  recurr 


(;i] 


^-"/  Feot,...,  S,,.,,,,,,,  ,  ro.,Ur.aion. 


n.onth  l,oforo  ad, .Lssion  •  „o  dZf  ''.^,^";--"--  H.  wa.s  ill  fo..  , 
irr^ular  fev.r.  This  pw"  .'"'''''  '".*/r^f'>-  ^"-"*-"«  and 
-e  spots,  no  special  onh^^  1  1;X:"  V  ?"''^'  ^^'^"-"'-•k^' 
'" -y  way  suggested  a  n.:Uaria;L  •;:'"'•  ^"  '"^"'''^'^  "'  ^''"  "^ 
J'K'  'ollowinsr  fnsf.  ic  *iw       i 

'''"od,  subsequently  develoned  tv,  l    -'r.-  "  ^'•^■a""nation  of  his 

a^ed  20,  had  during  rxri'V:;  7""^  ■''''  '•^^■^"^' "  "-" 
eough,  occasional  noseJl .  dfnt  a  Th  '  r'.f ""'  ''"■''>-''^'  -"' 
Oc'tober  16th,  the  ten,.erature  's  Z^T^rtK  ^"  ^'^'"'^^-"' 
"'■  the  17th  to  9r,o.     i^,„  „  2,ri  '  r"  ^''^  '"  ^^'^  ^''•"b'  "-rning 

:  the  blood.  He  was  o  U^^^  ™t ^""  '•""'  '"  '^  ^"'^-^ 
''=^y-     On   the  17th  the  Ivn  ZJ  '      "  ^'''"''  ""-*=«  tin.es  a 

rose  to  noarlv  lO.^',  t  h.,  fe  i  .  ro       '     'Z  "'"''  *'"  ^-^l-'atur,. 
"ormal  at  8  a!  n..     T  7  1^^..^:"'^';:'"*  *''^'  "-*  ^^^K  and  was 
-<•  the  ,„i„i„e  was  cont;"  d      On  l'"', «T"'  ^"^'''"'  '"'-'""-t, 
^'2nd  the  tcnperature  J  ZLl  or      ^"        \  ''^''  ''^'''  ^^'^^  and 
I'--a<nre  had  been  taken      U,  "    «     '^^''^^J'--^-    A  two-hourly  ten. 
g-ins  of  quinine.     He  ha<i  no  l!    f '"'      ''"  '^"^  *"  ^"^  ^^J^""  ^0 
•'-1  disappeared  fron.  th    1  ood      At  «"'  '"'  *'.'  ""'■"•'^^'  J'^-'^- 
ature  was  97.oO.     At  4  p.  n     it  wafoso"  "it"  '^  'n"'  *'"^  *""J-- 
'  "  --cning,  and  at  12  /nidnigh    it  ^s  ^02  30"'"?  ''  ""  *'^^"'^^'' 
;t  was  102.2°,  rose  throughout  the  dav        w-    "        '^'  "'-"'  "'"''"'"g 
105°  :  so  that  within  the  I4  In  u..  fro"  '  T       """  '  '"  '  '''  "'•  "^  at 
-  the  23rd  the  ten.per:ttr    d^  L'/o"  ^^/^^fSnd  to  4  p.  .. 

'•>■«  -as  a  recurrence  of  the  n.n Ma  "  L'it-    f  th"  ^  "'  ^''"'^^'^^ 

uaria,  ,n  spite  of  the  administration 


62 


miWim  OhI,',: 


[62 


of  the  <niiiiiiie,  of  which  he  had  liud  90  {rraiiiH  up  to  10  a,  ni.  on  th. 
23r(l.  From  8  p.  m.  on  tho  'I'MA  throiijihoiit  the  '24th  and  'lh{\\  the 
tompcnitiirc  remained  practically  Ix'twccn  lO.T  and  10")°,  uninlhi- 
onccd  hy  the  (juiiune  (wliicii  was  continued),  and  oidy  inlhiciiccd 
fllightly  l>y  spon-,nnu;.  The  quinine  was  continued  until  noon  on  the 
26th.  The  whole  appearance  of  the  man  was  Hu^'gestive  of  typhoid 
lever,  and  subsequently  spots  appeared,  the  spleen  enlart;ed,  mid  the 
disease  ran  a  perfectly  normal  course,  tyi)ieal,  but  of  great  sevcritv, 
the  temperature  not  fallinfjf  to  normal  until  between  the  fifth  aiid 
sixth  weeks.  The  tempcirature  chart  annexed  t^ives  a  fac-.siinilc  ol' 
the  ward  temperature  chart,  and  shows  the  ingle  nudarial  paroxvsni 
and  file  abrupt  onset  of  the  typhoid  lever  uid  its  pi  :sistence.  Th,. 
patient  had  in  all  68  baths,  and  made  a  good  recovery. 

0. — (^omi'licationh. 
Digestive  Sv8tem. 

[a)  Parotitic. — This  occurred  in  five  cases,  of  which  one  died.  It 
occurred  in  the  left  jjarotid  in  two  ;  in  the  right,  in  two  ;  on  both  sides, 
in  one.     [n  three  cases  it  was  opened  ;  in  two  the  swelling  subsided. 

(6)  Mekna  occurred  in  eight  cases,  of  which  three  proved  fatal. 
Notes  of  the  fatal  cases  have  been  given.  Hos.  No.  6086,  Patrick 
S.,  aged  27,  had  a  very  protracted  attack  of  typhoid  fever ;  was  in 
hospital  67  days,  had  87  baths,  a  long-continued  high  fever  verv 
little  influenced  by  baths  or  sponging.  He  had  at  intervals  ten 
hemorrhages,  none  of  them  very  large. 

Hos.  No.  6198,  Wm.  P.,  aged  32,  also  a  protracted  case,  had 
repeated  hemorrhages,  but  m       \  n'y  severe. 

Hos.  No.  6235,  Jos.  R.,  agd  J,  had  one  hemorrhage,  not  more 
than  two  ounces. 

Hos.  No.  6320,  Wm.  Mc^I.,  aged  32,  had  a  single  small  lieiiK.r- 
rhage  from  the  bowels  following  prolonged  constipation. 

Hos.  No.  7318,  Wm.  p].,  aged  38,  had  moderately  severe  attiick 
with  relapse;  small  hemorrhage  during  relapse. 

With  the  onset  of  the  hemorrhage  the  baths  were  omitted.  Tiie 
pill  of  acetate  of  lead  and  opium  was  given,  and  cold  applications 
applied  to  the  abdomen. 

(c)  Hemutemems.—:io\m  M.,  aged  40  (Hos.  No.  1683),  admitted 
August  21st,  1890,  with  a  history  of  illness  of  some  weeks'  duration, 


flic  chief  syi 

negative,  an 

feinperatiire 

li;nl  vomitinj 

i-h-l)rown   /) 

disintegratioi 

the  29th,  ;{0 

evidently  con 

"laterlal,     /[ 

.Vkhvoiis  Sv 

^«)   Tifphold 

pcarance  of  tl, 

'"'fi),  admittc 

("itcliing,  whi 

l«'<'<>nies  uiicon; 

imve  irregular 

[lersisted,     Th( 

"''iinsoiind  min 

^^'1  admission 

» 'th  scars,  a  hir 

and  one  on  the  i 

p\'('  an  intellig( 

file  examination 

""'1  of  the  musci 

the  legs.      The 

"fi.vthmical.     Th 

'''ere  was  no  hem 

dark-colored  spot 

''".trer  of  the  right 

^"'•'iig  the  first  w 

"■"'•«e;  thus  on  ti 

"  Patient  is  worse 

to  feed  herself,     'f 

'iHi.selesoftheface 
"  ''ttle  distance  off 
"w.v  ehorea  except 
"^'•"     From  Marc] 


f);{j 


^'^prcifif  Features    <..      , 


"'•  -"f '.  -WU.  and  ;jist  thv  .uJ  ""•  '"  •'"'""'f'T.     ()„ 

""'■^""-  ''«'"-'-• -;\.;.j'::::; '-••'7''. iv.,.,da^ 

"f  "i.Kic  ;,  ^,,,,,1  recovery. 

N'KRVOtJS  SVSTEM. 
'«)    Ti/ithoiil  Jhrr  in  a  ra^      ' 

On  adiiiissioii  she  wa^  u„ll 

^""'  -'«  o"  tl.o  right  sideof, he  :'•;"'  ""  ^''"  '"•'''^-  '>'-tf.e  nose 
;;-■'■  -  ".telllgent  aceo„„t  of  h^  ",„^  "  ""^  '-'-•fv  rational  anc 
''";-:";""a<ion  she  had  inv,.h,  ,""^7"  ^'^"''--^'b'  ^I-rin, 
"  "^  "'  f'H'  .nusoles  of  the  truni      'r   '        "'''  '""^•^"'^■"tsorthe  arnn 

J' '^'^r- ,  ^^'-  "-ven.:;rtere  :d;r"r'''''^''-^--'i"i 

.V^hm.eal.  Therefle.eswereTon/e  ;'•'"'■''  '""^  -"'<'-'/nnt 
I't''-'-"  Has  no  heniiana.sthesia  no         ?        "'"•^■««"'.  «ensafio„  .,,„d 

-'--''-1  spots  on  th^^riT  .;"":'!""••  ^''^■'•^'  -■•<■  --  ai 

^"^-  of  the  right  hand,so  flat     1 V'?""'^  ""•^■^''"■^  •"'  "'«  H"' 

D"nng  the  first  week  in  hos      .;    l'     '*''''r'  '"''"'-•^'ix'ta.s.siun'; 

:-;;  thus  on  the  2«th  o/  F      J  ,:  7:^'':'''  I"— ^s  heeani: 

Patient  is  worse;  movements  T-  '""'''  '''«  ft'llouing  note  • 

^0  ^eed  herself.     There  a  e  ,     ,;  "  ."T^  ^  V"^^--  that  she  is^,;    J 

7-'- of  the  face,  hands^:  d  ^.:  ''"  ^'^'^^^'^-^''-  i'-'-'g^  of  tl 


64 


William  Osier. 


[61 


ascending  temperature,  until  it  reached  104°.  She  comi)laincd  of 
aching  in  the  hack  and  legs.  The  tongue  became  much  furred.  The 
fever  persisted,  and  on  the  11th  several  very  suspicious-lool<in<!;  sjwts 
were  seen.  She  developed  a  very  well  characterized  attack  of  tvphoid 
fever  of  moderate  severity.  As  the  fever  developed  the  choreic 
movements  became  much  less  and  gradually  disappeared,  though  at 
the  height  of  the  fever  she  had  some  slight  tremor  and  subsultus. 
The  fever  ))ersisted  until  April  3,  and  then  she  made  a  very  satisfac- 
tory convalescence.  With  the  decline  of  the  fever  early  in  April  the 
choreiform  twitchings  gradually  reapjjcared  and  became  almost  as 
severe  as  at  the  time  of  her  admission. 

This  patient  was  in  hospital  exactly  thirteen  days  before  the  initial 
rise  in  the  fever.  There  were  several  patients  with  typhoid  fever  in 
the  ward,  and  one  in  the  next  bed  to  her,  so  that  it  is  possible  tiiat  it 
may  have  been  an  instance  of  ward  infection,  though  the  fever 
started  within  the  limits  of  incubation  of  an  outside  contagion. 

(b)  3Iel<nicholi(t. — In  three  instances  the  patients  during  conval- 
escence became  profoundly  depressed  and  melancholic. 

(xeorge  W.  (Hos.  No.  3922)  was  admitted  September  24th,  18f)l, 
in  the  third  week  of  typhoid  fever,  with  a  temperature  of  10:3''  and 
with  a  marked  splenic  tumor.  The  patient  had  only  three  baths,  aiul 
the  temp(>rature  was  normal  within  a  week  after  his  admission.  He 
entered  upon  a  very  satisfiictory  convalescence.  On  October  Kith 
after  he  had  been  up  for  three  days,  it  was  noted  that  he  iiad  a 
peculiar  mental  condition,  having  an  idea  that  he  was  going  to  die. 
Within  a  week  this  became  much  more  manifest.  He  thought  that 
he  was  going  to  be  executed  and  was  very  much  frightened  about  it. 
He  saw  and  heard,  as  he  insists,  the  headsman  icad  his  coi-.dt nina- 
tion  to  death.  After  a  few  days  of  this  delusion  he  said  that  he  was 
ashamed  of  himself;  then  he  became  again  very  apprehensive,  and 
about  the  second  week  of  his  convalescence  sank  into  a  state;  of  pro- 
found melancholia.  He  did  not  speak  to  anybody,  would  scarcolv 
answer  a  question,  ate  little,  slept  badly,  and  looked  very  much 
depresc  d.  His  physical  condition  improved  after  the  middle  of 
October,  and  on  October  26th  he  was  taken  to  his  home  by  iiis 
i'i  lends,  still  very  melancholic. 

Pauline  L.,  aged  28  (Hos.  No.  5685),  admitted  August  4,  18'J2. 
This  patient  had  a  very  severe  attack  with  a  well-marked  reinpsc. 
She,  however,  took  the  baths  well  and  had  no  special  delirium,  l)iit 


once  or  t\v 

fo  "ornial  i 

(lays  of  apyr 

and  could' s 

iH'urly  three 

distress  aboi 

going  to  get 

upon  convale 

more  cheerfu 

Henry  N., 

1892.     He^v 

moderate   but 

He  was  ahvay 

upon  the  con 

"onld  not  tal 

'January  he  h; 

rapidly  in  \veij 

very  much  in 

liis  mental  con( 

{<')  Hysteria.- 

Ill  one  (Hos.  I 

tlie  baths.     The 

deal  about  them 

tenderness  and  c 

of  the  l)ody.     T 

The  second  ci 

iioimced  hysteri, 

tliroughout  the  g 

ber,  at  5  ]>.  ,,1.,  h 

restless,  the  eyes 

to  his  throat  and 

•'t  fi  time.     He  h( 

"Ponit-     The  ex, 

»'''^'''  he  did  not 

''ody  to  ami  fro. 

"'"""■"g  he  had  til 

behaved  queerly  a 

"«i'"ced  hysterica! 

leased. 


b',5J 


^'^'^ ;^  o^  apyrexia  she  was  profo;„  d1  1'  T     1  'T"^  ^'^^  ^^«^'«»  or  eigh 
and  ^Id  searoeh-  bo  .ncSueodt  ;;^^^''^;:  ?'^-f  -'"^l  not  s,^ 
"^  '•'>  three  weeks,  she  vvas  vctv  ne-T;  '  ''^''i''''  "''i^f'  Jested 

'i-'^tress  about  the  heurt   -in  1    I     u"'  ''"'"PJained  a  ,n-eat  de-d  nf 

,   He"0'  N,  aged  32  (Ho;  xlU,.         '"'*'''>'  "^'omv. 

''f     Ho  was  ud„„-„od  ■    -.W,  :r'  r'f'W  N„ve;„W  ,,,„, 

"'  '""^h  in  spirits,  and  when  he  u!   ^-    .      """'>'  =""'  improved 

tenderness  and  coniphiineci  of  .t  ,  u    '  ^'"'^  '^'^"  '"'''rJ^'ed  genera 

^^:^  -b-.     The  con  Jll^e  'ir'^t:"'^""  ^"'^'  ''""^^^ 

rhe  second  ease  (Hos.  No   372lT  '''  ^^^'>«fi^«torv. 

;;-"eed  hvsteria.      H.  had  a  .teU,  's?    '  "^''  '''  '^^'^  "-«^  !>->- 
l-ughout  the  greater  part  of  S„      "'  A""^'^  «^"  ^--,  Jas  in, 
;"•' «^  5  p.  n..,  he  eomplained  tf^n^!;    .^"  ^''^"  ^^^h  of  Septen.t 
-  less   the  e^-es  were  closed,  and  he  J      f/"  "?"«"-^'"^^  --very 
fo  i^'s  throat  and  nodded  his  J„    ,        "'  ""*  '1'^^'-     He  „,ade  si.-ns 
''  '^ '--     He  held  his   otn    b    7^1f '^'  ^'^^  '^  -'"»^e  or   w^^' 
"P?"  't.     The  expression  ^l^^"^""  ^'  ^^^'^''  -^  «h.,t  the  teet 
;'^--''  he  did  not  do.     He  ro  Ld   "  o  "'"f  ^  '''"'  ^^  "'-  ^^^^ 
''ody  to  and  fro.    He  w.s  it  f  I    l^      ?  "^'  **^  ^''^^  ""d  swaved  hk' 
;'P'»f  1^0  had  the  sar  1ZZ^'''V'^^^-    '''^  ^^^^ 
helmed  ,ueerl.  all  through  hi  t^!?"'^  ""'^.  "'-  ^^^y  noisv.     JlJ 
-'"-d  hvsterieal  attaeks!      V^th '^e     TV''^  ''''''''  ^-7  Pro- 
^■«a«^'d.  'th  the  subsidence  of  the  fever    hev 


66 


William  Osier. 


[()« 


GuHtave  G.,  aged  22,  admitted  December  27th,  1891,  with  a  severe 
attack,  the  temperature  not  reaching  normal  until  January  23rd.  At 
times,  when  tiie  lever  was  high,  he  was  delirious.  On  the  eveiiii)u 
of  the  27th  of  February  he  had  a  pronounced  hysterical  attack" 
throwing  himself  on  the  bed,  breathing  in  a  hurried  manner,  and 
presenting  very  ])eculiar  twitchings  of  the  eyelids.  He  was  sjwkcn 
to  sharply  and  tlie  gas  turned  down,  and  he  went  to  slee[)  quietly. 
On  the  6th  of  March  he  had  a  second  attack,  while  sitting  in  a  chair, 
when  he  suddenly  comjjlained  of  a  pain  in  the  head,  fell  on  the  tloor 
and  behaved  '"n  a  distinctly  hysterical  manner. 

Perhaps  the  most  interesting  case  was  that  of  a  young  girl  aged 
13  (Hos.  No.  G497),  who  was  admitted  December  24th,  1892.  She 
had  been  ill  for  at  least  two  weeks  with  very  odd  nervous  symptoms, 
and  which,  though  she  had  fever  at  the  time,  were  regarded  as 
hysterical.  She  behaved  in  a  very  odd  and  peculiar  manner,  had 
crying  spells,  was  very  restless,  and  sometimes  quite  delirious  at 
night.  So  definitely  hysterical  were  these  initial  symptoms  that 
until  a  day  or  two  before  admission  the  case  was  regarded  as  one  of 
pure  hysteria.  During  her  stay  in  hospital  she  had  an  unusually 
severe  attack  with  a  definite  relapse  and  had  delirium,  but  no  subse- 
quent hysterical  symptoms, 

{(l)  iVe(m</,s'.— C.  W.,aged25,  admitted  October  8,  1890.     Patient 
had  a  moderately  severe  attack,  and  the  temperature  did  not  reach 
normal  until  the  27th  day.     On  October  18th,  that  is,  on  the  14th 
day  of  the  fever  and  while  the  temperature  ranged  between  102' 
and  103°,  she  began  to  complain  of  pains  in  the  arms.     Slie  had  not 
had  a  cold  bath  since  the  10th  day,  October  14th.     The  pains  were 
neuralgic  in  characte.-.     On  the  19th  the  note  reads,  "This  morning 
pain  is  very  much  worse,  she  can  scarcely  lift  the  arms.     There 
is  no  swelling  of  the  joints  or  any  tenderness  about  them  on  the 
firmest  i)ressure.     The  soreness  is  i)articularly  in  the  muscles.     She 
winces  at  once  when  they  are  grasjjcd.      The  biceps  is  i)articul:irly 
tender.     There  is  no  swelling  of  the  ulnar  nerves,  no  soreness  in  the 
brachial   plexuses  in  the  axillie  or  above  the  clavicles.     The  pain 
to-day  is  not  shooting  in  cliiiracter,  but  it  extends  down  to  the  fingers. 
There  is  no  numbness.    The  pain  is  so  severe  chat  the  arms  are  kept 
on  a  pillow  and  she  is  quite  unable  to  move  them."     On  the  2Uth 
the  note  reads,  "  Soreness  persists.     Cannot  lift  the  arms ;  fingers 
can  be  moved.     The  pain  is  continuous.     There  is  no  disturbance 
of  sensation,  no  pins  and  needles,  no  swelling  of  the  joints;  the 


'<',!J:n  are  nc 
'"itions  hav 
'I'l'tc  numl: 
s^volJen;  a: 
I'Sth  to  thi 
She  liad  Jea( 

temperature 

improved. 

pji'iis  still  i) 

wasting  of  tl 

^ery  rapidly; 

recovered   coi 

pain  in  this 

P-'itient  someti 

'    John  M.,  aj 

«»  tfie  10th  d!i 

he  had  been  al 

of  very  severe 

on  suddenly.     ' 

the  posterior   t 

tihhiUs  anticufe 

"dulling  of  sen 

persisted  and  it 

severe  post-typf 

"getter.     There  M 

'il^ial  muscles  ha 

Afary  McG.,  aj 

■■'bout  the  ejifj  of 

-■ittnck  of  typhoid 

'™g  t''He,  and  si 

'vere  discontinued 

""f  the  Gth  week  tl 

l^iK  while  the  tei 

•<"•  several  days   j 

sponged  with  ice-M 

f^tpainintheri, 

'^'  '"•'■^'1  out  coni 

'jWaeks  continued  b( 

';  f'e  n-ght  arm  th. 

0' the  joints;  no  pai 


67] 


Special  Feature.,    e 


)«^'«  «re  not  painful."     On  .N    oo 

'■•■•"""«  have  roJfevcd  th.  7       "    ^""^  ''"'  ""^^  reads    '<  Tl     X. 

'I"'te  numb      Sh  '"""  «"'"e»hat     Yn  .^     j '     ""  ^""^  -n^^^- 

temperat,„.e  :„::'"•  ^^''^''-^-ns  and  an     ^r-V'"''  ^•''"'^-• 
'"'Provod      o'  v"        '  grad.mllv  fell   a,„r  ^'^"'""">'-    '^^^^ 

\erv  rapidlv  •  f I,.      •  '^'^""' the  novf  fw^  '""'Sue'l;    no 

ne  nad  been  nlv«„  j  ""acK.     (j„  ^j.    «-  ,  ^'  t,  ioyi 

«.-..<We„|v.     £  "  "'^*°."'  ">")  Lack  of  .he  {T',!"'  7'l"»inod 
*«  posterior  lib!         :'':»'"'«' "■•"'•"Venos,!!?,,'-''  "'""''  ««""' 

persisted  and  it  ««^.     ,  ^^''^'if,^  loiit  thn  w.u    ,  ^  ^^"-^^ 

^"■«re  ,.ost-tvr      T^'^^  '"'""''•'^^^  ^he  Ltient  u  *'"''  ^«"^^'^>«« 

Mary  MefJ    o     ,  "''f*I>eared.  "'^'^^  '"  the  anterior 

••'l>0"t  the  end  of  the       ^    ?'•  '^*'-  ^'^^Sj,  admitted  J).       ■ 

i'"-^  of  t„,.;;:,tr'T:f  "^'^^•''-  ^-'^  ^r:t ''  ^'''' 

'«"g  time,  and  ,h,  ''"  t«"M^crature  Jcent  nn  f-  ''' '"''""« 

»-disco;tin:ed  t::;v"/'"''^  ^'-^^  =•«-  et,- ---an. 

«"t  the  Gth  week  thnAl      "      '  ""*'"'  ^''«  ^'"cl  of  the  ^.I       ,  '*''  ^''^-^ 
l^th,  while  theV  '^""^"''■^^"'•<'  fell  to\l       ,    ^""^'  ^^'^«"gl'- 

■'or  seve  al  d      ''!"''^^'^^^"'-«  ^vas  still  hil     h     '"''•     ^"  December 

sponged      thf   '"  '''  "^"■'"■^>'  «^'  10  °    a  ;TT  '^^"^  --tantlv 

^^^  0  ied  out  ''''"'"  ""^'  '■»  ^h    r    h     ff   !^  -'"Plain  of  very 
attacks  contin      Tf""'"'^'  "'">  "^''e  had   to     ''      '"'''  '''''''''-  that 
f"  ^'-e  r         a";„f  ^  «^-e„  the  14th  an      he  2  r  -T"''"''-     ^hese 
"fthe  ioint  -To  ^''f  ^-  "  -on  -subsided      h!rr''  ''"^'^^  — -tv- 
•     -  -  "0  paxn  ai,„g  ,^^  „^^^,^  trunks      si"  ""  '"^o'-«'«ent 

'•     ®^«  screamed  out  if 


68 


Wi!  mill   Osier. 


[f)8 


any  attempt  was  made  to  move  the  right  leg.  There  was  no  ttiider- 
ness  abont  the  hip,  no  swelling  of  the  knees,  and  repfeated  exanihui- 
tions  seemed  definitely  to  exclude  any  articular  trouble,  Graspincr 
the  leg  at  any  place  seemed  to  cause  extreme  pain.  On  the  18tli,  three 
patches,  like  erythema  nodosum,  appeared  on  the  right  foot,  one  at 
the  metatarsal  joint  of  the  small  toe,  one  midway  between  the  lied 
anvl  toes,  and  ore  on  the  outer  and  back  part  of  the  heel.  Tlux 
looked  like  largo  chilblains,  and  around  one  there  was  a  distinct 
bluish  discoloration.  The  two  smaller  ones  disappeared  within  a 
day  or  two.  The  larger  one  on  the  heel  remained  red  for  some 
days.  There  was  no  superficial  necrosis.  She  never  seemed  able  to 
localize  the  pain  accurately.  It  was  never  definitely  in  the  situation 
of  the  sciatic  nerve.  It  was  quite  uncontrollable  by  anythin-;  Imt 
morphia.  After  causing  great  anxiety  to  us,  and  distress  to  tlie 
patient,  for  nearly  ten  days,  the  pain  subsided  and  had  disapprared 
by  the  25th  or  26th,  two  weeks  at  least  before  the  temperature 
became  normal. 

Wm.  McM.,  aged  32  (Hoj.  No.  6329),  admitted  Nov.  19th,  189:^, 
at  about  the  .'^econd  week.     The  attack  was  of  moderate  severity,  the 
temperature  ranging  between   103°  and  104.5°,  and  not  fallilijr  to 
normal  until  the  fifth  week.     Just  about  t.^  a  time  the  temperature 
became  normal,  that  is  on  the  12th  of  D<   -jiber,  the  patient  com- 
plained of  general   soreness  and  pains  iii  the  limbs,  particularly  in 
the  arms,  and  he  winced  on  pressure  upon  the  forearms  and  anus. 
He  had  been  in  very  good  condition  and  convalescence  seemed  well 
established.     The  grasp  of  both  hands  seemed  weak,  but  particularly 
the  loft,  and  he  complained  of  a  sensation  of  pins  and  needles  in  the 
left  foot.     There  was  no  tenderness  along  the  nerve  trunks  ;  no  pain 
on  pressure  on  the  muscles  of  the  calves;  he  winced  a  little  when  the 
muscles  on  the  right  thigh  were  pressed.     On  the  17th  of  Doeember 
the  note  reads,  "Lett  arm  looks  somewhat  swollen  and  feels  tense. 
It  is  not  red;  the  temperature  is  not  elevated.     He  moves  the  mus- 
cles with  difficulty  and  says  the  arm  is  very  sore.     On  the  inner  part 
of  the  upper  arm  there  is  very  great  tenderness  r'or  "  the  course  of  the 
brachial  artery  and  of  the  nerve  trunks.     0'  .     •  '  -ar  nerve  is  iLso 
somewhat  tender  at  the  elbow.     There  is  teLde-—.     of  the?  muscles, 
particularly  of  the  biceps  and  of  the  extent   as  of  the  upper  arm. 
There  is  no  anesthesia ;  no  sensation  of  pins  and  needles.    All  move- 
ments in  the  limb  cause  him  pain.     There  are  flying  pains  in  the 
legs,  but  no  swelling:  no  tenderness;  knee  jerks  were  incre.ised;  no 


ankle  cloni 
"ally  di.siip 
muscles. 

(c)    Local 

^946),  admi 

very  peculia 

of  the  heel. 

the  region   ( 

extends  aloii 

red;  there  ii 

affected."     "W 

the  region  of 

si)otsofredn( 

right  ankle  a 

flii'h,  raised  ai 

in  the  rig'^t  \i 

attack,  and  bj 

during  con  val( 

out  any  rednes 

(/)  Tender  2 

imrajsthesia—ai 

have  been  terra 

I'athed  cases,  vi 

tlie  soles  and  d{ 

t'hiiblains  has  i 

special  coniiectii 

The  condition  d 

been  given,  and 

bedclothes  on  th 

"iiy  change  in  tii 

^vhich  is  not  unc 

feet  in  typhoid  ai 

'oii^'li  on  the  toes 

tbe  ward,  J  have 

through  the  l)edc 

salutation  which  1 

sideration  by  a  bu: 

be  due  to  a  drying 

macerated  by  the  r 

'a.vers  beneath,  bu( 


69] 


*"'"  """"'"  '^"""^  -"  a.,,,„,,„,. 


ankle  clonus."     The  «vv,,ii- 

jy  peculiar  condition  of  tlJl^"^^  f  7!')-  f  -  -InWs.ion,  a 
J^-  J'eel.     The  note  reads,  "  t"  si      f?   ""  ^'"  "«gl.borho;d 
^''     -^-on  of  the  heel,  are  swol  on       V  '"'  I>'"-^'«"'"'-ly  in 

extends  along  the  lateral  aspect  of  th";  "''  *'^^'  ^''^  «^^  -dne 
-di  there  is  n^arked  swelli  ^  ,;Vn  ,  7  /^'^^  ^^^  -  a  bluish 
effected."  Within  a  week  the  f  ij  n'r;  '  'T ''  ^'^  ^«^«  ^^^  -^ 
the  region  of  the  heel,  but  on  tZT^  "'"^"'^  ^i'^appeared  from 
^17;  of  redness  and  idel,  a 'd  r""  f  '''  '^^^  *''-«  -- 
2^t  ankle  and  one  on  the'o  e'  de  oTtf  T  "'^  ''"^^  ''''^  '^^  ^^e 
di^h  raised  and  swollen.     On  the  2t?/.  '^^     '^''^^«  ^^'^-'^e  red- 

-  ^;e  rig;-t  wrist  without^;  ten  ;'''t/*''''"^  '''  ^^^' r>l 
attack,  and  by  March  30th  the  tlm  "f .         '  ''"''^"^  '''''d  ^^  '  "-Id 
d'Ting  convalescence  some  n-  «  il  r^'        !"'  "''"^■'^  "«^"'al-     He  ha 
out  any  redness.  P'""  '"  '^'  ^'^'^t  forearm  and  wrist  will, 

{f)TmderToe.s-~A,         v 
para^sthesia^as  these  cliZ,  f  ,"7'"''  ,''"'  ''^'^"''^'-  ^"^^  of  aero 

-  been  termed  by  Fr.^h If  1^'"^^'^  "'^"'^^"^^^  «^  --^^- 
lathed  cases,  vi..,  exquisite  ser  s.V"  ^  '"^  '"  ""  """'l^er  of  the 
;  esoles  and  dorsal  Ln.1  7^^''  f  "^  *^-'  --^^--^ 

'uWams  has  frec,ue„tlv  been  not  d  .".f/ V'^^^^'"'"""'^^  •'^'■""''^•- to 

Pecal  connection  has  b;en  obso  vll,        ''  '''''  ^'"'^  »^"fl''  '"'t   no 

ri.e  condition  develops  abou   a  Jed' orT'T  "  "''  ^''^'  ^"'^^  ^oes 

b'en  given,  and  the  first  complai^     ?      '\t"''  ""''''  *'"«  baths  have 

bedclothes  on  the  feet      v"  r    J  '"""^'  "^  ^^e  pressure  of    h! 

2^-^^  ^»  ^''e  ap;  .^:r  ?r:,r '"^  ^'^'^  ^-  --^  - 

vhich  ,s  not  uncommon  in  the  nail    /     '  ?"'^'^  *^'^  ^^How  tin<.e 
^«et  in  typhoid  and,  I  think   nth  '*"  ^'""^''^  «°J  ^oles  of   L 

;;-'"  on  the  toes  caused  si:'^:fr'f-^«'.«^vers.     The  sHght  ; 
f'>e  ward,  I  have  long  h-ul  !  !  .       I''''^-^'nf?  ^on.  !.rd  tc  bed  i, 

^''^ough  the  bedclot  t  a  .,V  :'>"'-^^"""S  ^^^^eetof  .p  " 
^^'"^^^ion  which  has  ^J^^^^^^:  ''  1'  "'^"^"'^  ^^^  ^a 
"«leration  by  a  burst  of  tears     T   I  '"'  "^  ^''«  ^'='«es  under  co„ 

''  ^'-  ^o  a  drying  and        Li,  .t"f  "^'  '"^  *^"*  ^''^"  l-'"  "% 


GU 


^•er.«  beneath,  but 


the  skin  has  always  looke, 


pressure  of  it  on  tl 


'e  sensitive 


I  " 


natural,  and  though 


70 


WiUidin    Osier. 


[70 


thoro  lias  mvor  hern  any  inipairmont  of  li.nsrular  j>o\v.t,  wt  havo 
gradually  been  Uul  to  regard  the  condition  i(«  a  local  nenritis.  All 
the  ca.sos  recovered  without  leavinp  any  i.  "ilec^..  Tiiu  irejutrjlnt 
was  not  very  Butisfactory ;  strong  cocaine  solutions  on  cotton-wo.,1 
proved  i)erhaps  the  most  efllr;aeiou8  remedy. 

RkSPIUATORV  8 V'STEAf. 

OetJcmuoftJH'GloVh.-Thii  ■•■,.^o  ,:as  been  -iven  among  vh.  fVial 
cases  an<!  need  not  be  here  again  considered,  ri.uv;  ,v.,)rc  .<,  vcn 
oases  of  immmonia,  two  of  which  died,  a/ui  the  cirvails  are  given  in 
Che  s-^ction  dealing  with  the  fatal  cases.  One  of  tiiese  was  specidiv 
^<d^i  inig  fro.u  ihe  fact  that  the  diagnosis  was  made  of  pneumonia 
and  tii(.  typhoid  fever  was  not  detected  until  the  post-mortem.  Of 
the  f.'  e  case;-  which  recovered,  in  not  on<>  was  the  pneumonia  exten- 
sive, and  fl..,  diagnosis  rested  upon  defir.ite  dulness,  with  distinct 
tubular  breathing. 

P/««r%.— There  were  only  two  cases  of  :  his  complication 
Wm.  E.,  aged  38  (Hos.  No.  7218),  admitted  with  a  well-marked 
friction  and  crepitant  rales  in  right  axilla.     There  was  no  effusim, 

Frederick  S.,  aged  20  (Hos.  No.  192),  admitted  August  10,  1889 
with  perfectly  well-marked  signs  of  eifusion  at  the  left  base,  with' 
dulness,  absence  of  tactile  fremitus  and  of  breath  sounds.  Tlie 
effusion  gradually  disappeared  during  convalescence. 

CiRcuj-ATouY  System. 

Ajiart  from  the  gradual  failure  of  the  heart  power  with  the  bodily 
strength,  generally  indicated  by  a  shortening  of  the  \oiyj:  ])ause  (the 
foetal  rhythm),  there  were  few  cases  presenting  cardiac  complications. 
A  heart  murmur  was  present  in  many  instances.  This,  of  course,  was 
not  regarded  as  in  any  way  indicative  of  endocarditis,  but  d.iesimplv 
sometimes  to  weakness  of  the  cardiac  muscles,  sometimes  to  the  con- 
dition of  the  blood. 

Among  the  fatal  cases  there  has  already  been  referrc.l  to  one  in 
which  there  was  pronounced  arrhythmia  orlis.  There  was  no 
instance  of  endocarditis,  and  among  the  fata^  .-  s,  as  will  have  been 
noted,  there  were  few  even  of  those  with  si.  -  ;  of  prooTcssive  heart 
failure  v:<y«:h  had  marked  fatty  degenerajiovT  of  the  muscle  substance. 
There  v-v  no  complications  on  tl,  -art  of  the  arteries.  In  a 
case  of  aortic  Insufficiency  with  typhoid  i-v.  r.  the  murmur  inoroa^od 


7iJ  ,S 

ill  intensity 
we  thought  I 
tin's  there  wa 
Phlebitis.-. 
1892,  about  t 
J)rotracted  or 
about  tile  end 
tstablishod,  ti 
of  October,  t\ 
gradually  exte 
and  was  imrd  i 
and  inner  aspe 
tile  fever,  and  J 
Wm.  S.  W., 
1890,  on  the  si; 
tenijieratiire  wa 
iiad  tenderness  i 
of  the  internal  ; 
pain  and  the  leg 
in  femoral  and 
and  the  comjjlic 
He  was  discharg, 

CuTAiVKOUS  Sy.S'l 

Profuse  drencJi 
"limbers  occurred 
""•i  distressing  in 
adclition  there  de\ 
«^u]'l  not  be  classi 

Osseous  System. 

i'mostilis  occurrt 

«iien  convalescence 

but  was  u  tender  sw 

"fe'l't  tibia.     ltai,a 

OtUis.^There  we 

iff)  Errors  in  Dia, 
-—-  -i  patient  froi 


[70 

llJV<> 

Ail 


71J 


1" '^  "('tons.  7] 

mi*:":,:;;,,"™'"""  r-'''™«        «'<'»«r.ii,i«,  but  „,■ 

protruotw    one    ami  fi    ",       "'® '^'^•'"'l  weok.     T1,p  ^„.         ^"'^^'^1' 

Cutaneous  System. 
Profuse  (Iroiiciii,,,,  «„„,  „ 

"■■■1  <iis.rei ;    !.f ■'  r ■'•  ■"»>•  »■"■«  i»  Li.fr '"  '"'■''" 

"«-' «-  i-e  oiassi«er  f:i:,::-- """'-  ^^-'.■«e«i;,  .i: 

Osseous  System. 
^'■nW^/s  occurred  in  the  rio-hf  ,;,  •    • 


72 


William  Osier. 


[72 


of  typhoid  fever  when  the  condition  was  in  reality  malaria.  On  nior*' 
than  one  oecasion  a  i)atient  has  had  his  head  shaved  and  has  IkkI 
baths  for  twenty-four  hours  before  the  error  was  corrected.  Such 
mistakes  have  not  been  so  common  since  a  thorough  examinatiim  nf 
the  blood  in  every  case  of  fever  has  been  made  a  matter  of  routine, 
but  we  have  been  occasionally  caught  nai)i)ing,  as  when  a  patient 
has  had  malaria  for  some  time  and  has  been  taking  quinine,  so  that 
the  organisms  are  scanty  or  absent  for  a  time  from  the  blood. 

In  two  very  interesting  instances  the  mental  condition  at  the  onset 
of  the  disease  led  to  a  mistake.  In  Hos.  No.  6497  the  error  was 
not  on  our  part.  The  patient,  a  young  girl  of  thirteen,  had  been 
treated  outside  for  a  week  or  ten  days  for  hysteria,  and  certainly, 
according  to  the  mother's  account,  the  symptoms  which  she  presented 
were  (luite  typical  of  that  disease  (the  performance  of  odd  and 
anomalous  acts,  with  laughing  and  crying  spells),  yet  the  fever,  which 
was  high  when  she  was  admitted,  should  possibly  have  given  a  clue 
to  the  condition,  about  which  there  was  no  question  when  she  ciuue 
under  our  observation.  The  second  case  was  a  young  woman,  aj^ed 
28,  whom  I  saw  on  a  Sunday  afternoon  in  the  admitting  room.  She 
was  completely  "  off  her  head,"  and  the  account  given  by  the  friends 
was  so  unsatisfactory  as  to  the  duration  and  mode  of  onset  of  the 
trouble  that  I  told  Dr.  Hoch  that  I  did  not  think  the  case  a  suital>le 
one  for  admission,  regarding  it  as  an  instance  really  of  mental  dis- 
ease. The  temperature  was  very  slightly  elevp.ted,  the  tongue  was 
clean,  and  the  whole  behavior  was  so  much  suggestive  of  mental 
aberration  that  I  was  comi)letely  led  astray.  Fortunately  Dr.  Ilurd 
saw  her  subsequently,  and  it  was  decided  to  admit  her.  She  had  a 
mild  attack  ;  the  delirium  disappeared  and  she  had  no  serious  .symp- 
toms. 

In  only  two  cases  did  the  anatomical  correct  the  clinical  diagnosis. 
Both  of  these  are  given  fully  in  the  history  of  the  fiital  cases;  one 
(Case  11)  was  the  old  man,  aged  70  (Hos.  No.  1814)  who  was 
admitted  in  a  condition  of  cachexia,  with  pneumonia  of  the  right 
lower  lobe.  In  the  other.  Case  18  (Hos.  No.  5556),  the  patient 
had  been  in  the  hospital  a  year  before  with  severe  entero-colitis,  and 
when  admitted  had  diarrhoea  and  an  irregular  temperature,  and  not 
■  unnaturally  he  was  thought  to  have  a  recurrence  of  his  former  severe 
trouble.  The  only  suggestive  feature  in  his  case  was  the  presence  of 
the  diazo  reaction  in  the  urine.  He  died  on  the  seventh  day  after 
admission,  and  the  autopsy  showed  the  lesions  of  typhoid  fever. 


V._ON  THE  iVRlTROsiS  FOr.LOUTNG  ENTERIC  PEVEIl 
KNOWN  AS  "THE  TYPHOID  SPINE." 

Bv  WILLIAM  OSLER,   M.D. 

In    IHHH  Dr.  (Jibmy,  of  New  York,  ,losoril.ecl  at  th.  AnuTicun 

Or  hojuodic  Association  a  8.q„el  of  enteric   fever  whiel,  hr  ..alled 

n,e  typhoHl  spme,"  .,       whieh  he  rej^arded  as  u  perispomMitis 

me.an,n.  an  ae.ite  .nthunmaticn  of  the  periosteum  and  the  fd,ro,.s 

tn.etures  ul„d,  iiold  the  .spinal  eol.nnn  to^^ether."     He  .stated  that 

h.s  reason  for  the  use  of  the  tern,  "was  the  production  of  acute  pain 

on  the  sl.KW,test  movement,   whether  lateral   or  forward,  and    the 

al'  .nee    of    any    marked    f,  l.ril,.   disturl.anee   or    neuralfjia."     He 

de.scr.l,ed  four  cu.ses ;  in  the  first,  a  lad  of  15,  towards  the  (.ul  of  <.on- 

valescence,  complained  of  severe  pain  in  the  hack,  partieularlv  in  the 

lumbar  reg.on,  and  especially  after  any  movement.     There  was  n.> 

d.,s.ase  of  the  hone,  no  pain   in  the  distribution  of  the  sciatic  or 

aiiterior  ejural  nerve.     He  wa.  .seen  in  the  autumn  of  1882,  with 

Dr.  Beverly  Robinson.     A  spinal  brace  affbrded  relief,  and  in  the 

'       ^e  of  two  or  three  weeks  he  was  practically  well,  but  the  brace 

wa.    A  orn  for  more  than  a  year. 

The  .second  case,  a  younj;  nutn  aged  24,  had  an  attack  of  tvphoid 
fever  which  ran  a  normal  course.  After  convalescence  was  w.-ll 
established  he  cMuplained  of  pain  in  the  back,  but  he  was  able  to  be 
ui.  and  about,  and  play,.!  tennis.  After  a  fall  tennis  the  p-iin 
became  very  severe,  and  he  sufK^ed  so  excruciatinglv  ,hat  h.  could 
only  rest  ,n  a  recumbent  posture.  Deep  pressure' ,  ;er  the  iliac 
region  on  the  left  side,  and  lateral  or  antero-posterior  motion  of  the 

I'-sisted  from  the  latter  part  of  iNovember  until  the  beginnin..  of 
January  hut  it  was  not  until  March  that  he  was  ab.c  to  get  aboi^;. 
ihe  third  case^  a  lad  of  18,  had  typhoid  fever  in  November,  was 
iva  escent  by  December  27th,  and  went  to  Ne,,  York.  On  January 
10  h  ho  fell  win  e  skating  and  struck  his  left  hip.  A  week  after  thi^ 
hehadpainin  the  repou  of  the  lumbar  spine.  The  .stifFness  became 
more  marked  and  the  pains  increased  in  severity.     On  the  lOtb  of 


74 


WiUiam  Onler. 


[74 


** 


February  he  went  to  bed  and  was  ..en  b>-  a  «urgeon  in  Albany,  who 
regurd«.d  tlie  case  as  one  of  psoas  abscess.  There  wis  no  fever  n„ 
evident  idisease  of  the  spine,  h„t  the  patient  could  not  move  wit!,- 
out  ex(iui8ite  pain.     He  did  not  recover  until  Xfay. 

The  fourth  case  seems  to  me  to  belong  to  an  entirely  differem 
category  as  it  was  an  instance  in  which,  during  typhoid  fever,  the 
boy  had  kept  both  limbs  tle^  1  on  the  alulon.en,  and  .luring  conva- 
lescence  was  unable  to  straighten  tlum,  an  event  met  with  in  manv 
protractecl  illnesses  i„  which  the  patient  lies  curled  up  in  bed  witi, 
the  l€!gH  flexed. 

In  1890  in  a  discussion  at  the  Association  of  American  Physicians 
tollowing  the  reading  of  a  paper  on  some  points  in  the  natural' historv 
of  enteric  or  typhoid  fever,  by  Dr.  James  E  Reeves,*  Dr.  Loomis,  Sr" 
referred  to  Dr.  Gibncy's  observations,  and  to  one  of  the  cases  he  had 
asked  Dr.  Gibney  to  see.  Dr.  Loo.uis  knew  of  no  reference  in  literi- 
ture  to  a  similar  condition.  Dr.  Jacobi,  at  the  same  meeting,  besides 
protesting  against  the  introduction  of  a  new  name,  such  as  "  tvohoid 
sp.ne,  suggested  that,  in  the  absence  of  temperature,  it  might  he 
one  of  two  things,  either  a  neurosis  or  a  spondylitis,  re.uarking  that 
mi  d  forms  of  spondylitis  are  not  so  un(;ommon  as  they  are  l)eliev(Mi 
to  be. 

In  the  American  Text-book  of  Medicine  (page  90)  Dr  Pepper 
remarks  in  his  article  on  typhoid  fever  that  he  has  observed  in  h 
series  of  cases  "obstinate  peri-osteitis  of  the  sternum  or  of  the  crests 
of  the  il.a,  or  in  two  instances,  judging  from  the  location  of  the  pain 
and  from  the  effect  of  movement  of  the  trunk,  of  the  front  of  the 
spinal  column."     Eskridge  also  described  a  case  last  year 

I  have  not  been  able  to  find  any  other  references  in  text-books  or 
monographs  on  tyj.hoid  fever,  either  in  English,  French  or  Gernmn 
My  attention  hnJ  not  been  called  to  the  condition  until  recently' 
unless  perhaps  a  case  which  I  saw  several  years  ago  with  Dr  Gr-i- 
sett,  of  Toronto,  was  an  illustration  ;  a  young  officer,  invalided  Iron, 
India  after  a  prolonged  fever,  had  for  many  months,  on  the  slightest 
movement,  attacks  of  the  most  severe  pain  in  the  back,  which 
incapacitated  him  completely,  though  when  seen  by  me  he  looked 
strong  and  robust  and  had  a  good  appetite.  He  subsequently  got 
quite  well.  ^         ■'  ^ 


•Transactions  of  the  Association  of  Aii.^rican  PhysiciaES,  vol.  v.,  1890. 


75] 


The  Typhoid  Spine, 


7a 

Patient  was  Htronj?  and  well  uiitiljiilv  ISQo      »       i     .    , 
never.,  atta.k  of  typhoid  fever  w   hW^'R         '''"''' ^"""'^ 
nearly  three  months-  verv  slow!       T^  ^"^  """  '"   ''"'   ^«'' 

for  three  weeks,  whe'n  t^  role 7^  rT'"  "•  ."""^■""^'^  ^^«" 
Lack  an,i  hi,,s,  usually  of  tsho  in  ,  '^""'  ""''"  f^"'""  '»  *»'^' 
pain  in  the  ahdomen  of  Ijoh  he  'n  '"'''''' ""^^  ''"•''"-^•"•"«  "^ 
the  day.     He  had    o  t.ke  1     .^-^^'^  «»  «ometin.es  have  several  in 

weeksfhavin,  t  ueh'  ^  :^z  t^:  ^::fr:'T  "\ '-- 

the  front  of  the  legs      H..  nov.V  '    .         ^^  ^'"'^  '^"^  ^"^^n 

-y  paralysis.  Ifout  T^.ne  o  7h-""  ^ '  f""  '"■"  "^^'"""*'  ''"^ 
to  .0  out 'and  do  1  ^  "k  l^JT    '"^   T  ^'^    ^'"""^^ 

'•f  .^-ne  he  had  another  a  Hd  of  1  "'"".  ^"  '^'^  ^'^*^^'-  P"''* 
abdomen.  He  had  n  t  to  ^  t  be/  tT'  '""  '"  *'"  '""^  ""^ 
and  shootin,.  in  the  righ  Te.  from  the  h"  T  ""''  '"•''"^^'  ''^"» 
the  latter  n-^rt  nf  T  'j^  trom  the  hip  down  to  the  knee.     In 

in.  and  has  c  t^^^  ^T  rsi::;:^  1;^:^^^  r  7r 

pains  at  time.s  in  the  back  and  J,,  ih    i  7   present  he  has  slight 

aohi,,.  „ai„  W  .l,eS;t  '    '    ,  1r''C''''''•?-»™"" 
HB  never  vomits,  tl,ou,{h  h»  „fjn  i°7  '"'"'""'  "  «°°''- 
-ve.     He  .,„e'«„,e,  L/,- *:  ^     rr™-      ''°"^'=  "' 
Present  Condito^i.—Healthv   Inol.;,.           ,. 

lairly  well-doveloped  n,.^.:^'^^^^^''  ""'"'.  "'"■ 

a  neurasthenic  natienf     T  ;,..       i  ^  "'^  *^*^  "npre-ssion  of 

tender.     The  .hheZllJt  o^'T  ""?  ""  ""''   """'"'"^ 
hurt,  hi,,,  to  t.,rn  in  bed      H .  1    °^"""'''™«  '»  ">->  l>«clr,  and  it 

year  a,  beginning  i" , he  ;„,a^„fT,!'  f''"  ''"''"  "'''"''  '»  ''»-'  '-' 

kone»„nd^he„  !Xi:i     tZ^tfT'  "'•"""."'"  "'" 
trouble  was  thought  to  he  in  ih    ^  scarring,  the  chief 

Btill  a  little  ten^tL:     :]^^^  T\  "'  ''^  ^P'"'^'     ^^'^^  ^ 
-  -  -n  pressure  just  above  the  left  sacro-iliac 


76 


William   Osier. 


[76 


Kvnchondrosis.  There  is  no  tenderness  over  the  sacrum  itself,  or 
along  the  iliac  crests.  Patient  gets  out  of  bed  readily  and  stands 
well;  walks  with  a  natural  gait;  does  not  sway  with  the  eyes  shut. 
After  prolonged  standing  or  walking  lie  complains  of  great' iucreas^e 
of  pains  in  the  back.  The  knee-jerks  are  present,  a  little  exagger- 
ated;  there  is  no  ankle  clonus.  The  most  careful  examination  of 
the  spine  fails  to  reveal  any  signs  of  organic  disease.  The  urine  is 
normal. 

The  patient  remained  in  hospital  for  a  little  more  than  a  week ; 
took  large  doses  of  nux  vomica,  and  was  encouraged  to  believe  that 
he  had  no  serious  organic  disease.  Subsequent  examinations  gave 
no  additional  information,  but  the  patient  evidcmtly  was  highly 
neurasthenic. 


in 


Caiic  77.— A.  A.,  aged  21,  architect's  assistant,  seen  with  Dr.  King, 
May  10th,  1893.  Patient  has  always  been  a  healthy  man  and  has 
never  had  any  very  serious  illness.  He  is  not  of  a  robust  constitu- 
tion, and  though  bright,  not  of  a  very  strong  mental  fibre.  There 
are  no  special  nervous  troubles  in  the  family. 

In  November  and  December  last,  i)atient  had  typhoid  fever,  an 
attack  of  moderate  severity.     On  New  Year's  day  lie  sat  up  for  the 
first  time,  and  convalescence  was  gradually  established.    There  wcro 
no  sequelse,  no  complications,  and  early  in  February  he  went  to  his 
work.     He  gained  in  weight   ind  looked  very  well.     He  remained 
at  work  about  three  weeks,  complaining  only  at  times  of  pain  in  the 
back  and  of  being  very  tired  after  sitting  for  a  long  time.     One  day 
he  was  very  much  jarred  in  the  back  during  a  sudden  jerking  oi'ii 
cable  car  in  which  he  was  riding.     Early  in  March,  after  complain- 
ing very  much  of  his  back  and  of  the  pain  on  moving,  and  of  tired 
feelings,  he  took   to   his   i)ed,  where  he   has   remained   ever  since. 
Dr.  King  tells  me  that  the  chief  symptom  has  been  i)ain  on  move- 
ment.     His  general  health  has  been  excellent.     The  appetite  has 
been  good,  he  has  gained  in  weight,  and  he  has  slept  well.     He  has 
been  nervous  and  at  times  almost  hysterical,     ^yhen  (piiet  and  at 
rest  and  not  attempting  any  movement  he  does  not  complain  of  pain, 
but  on  turning  or  on  attempting  to   get  out  of  bed,  cv  even  the 
thought  of  the  attempt  to  move  the  legs,  is  enough  to  cause  him  to 
cry  out.    The  pains  have  been  in  the  lower  part  of  the  back,  extend- 
ing sometimes   up  the  .spine  and  down  the  back  and  sides,  more 


77] 


The.  Typhoid  Spine. 


77 


rarely  the  front  .f  the  le^  as  far  as  the  knee.     He  has  had  no  fever 
1.0  cmlls,  but  has  sweated  a  good  deal.     He  has  had  no  swellinro; 
the  Joints.  »tiuug  ui 

Present  M/on.-Patient  is  a  well-grown  young  man,  well  nour- 
ished, inuseulature  of  moderate  developn^ent.      The  pahus  of  the 
hands  are   mo.st  and  sweating;  he  was  somewhat  excited    and  at 
our  entrance  flushed  over  the  cheeks  and  neck  and  upper        t  o   th 
eiKjst.      Pace  does  not  indicate  any  speei.!   strength   of  ^character 
nuher  th.  reverse.     Pupils  of  medium  si.e,  equal,  active;   tong "e 
d-n.       Patumt  „,  the  dorsal  decubitus,  his  usual  attitude.      On 
pull.ng  down  the  bedelotnes  he  in.plored  us  not  to  touch  him,  as  he 
w..  sure  .twouhl  hurt  him  very  much.     The  abdomen  wa    full 
natural     ookmg.     On  palpation  he  con^plained  of  a  good  d^al  of 
P-"  m  tlK.  leit  iliac  region,  but  on  withdrawing  his  attention  and 
pressing  fombly  with  the  left  hand  in  the  region  of  the  heart  and 
asking  whether  he  had  pain  here,  the  right  hand  at  the  same  tim 
CM.  <1  be  pressed  deeply  into  the  iliac  fossa  without  causing  any  di  - 
.u-bance.      The  .leepest  pressure  in  the  lun.bar  and   ili.'   regions 
faded   to  reveal  any  glandular  enlargements  or  thickening.      The 
.nguinal  glands  not  enlarged;  no  special  sensitiveness  along  the  ante- 
rH>r   crural    nerves.      On    asking   him    to    lift    the    leg    he  said    t 
was  imposs.  le,  as  it  hurt  him  so  na.eh,  but  in  a  few  moments, 
ac.„g      e  hand  beneath  it,  he  lifted  it  apparently  without  pain 
\hen  hfted  m  a  semi-flexed  position  he  said  it  was  impossibi     for 
him   to   straighten   it,  but   in  a  few  moments   it  could    be  readi  v 
extended  and  he  straightened  it   easily  on    the    bed.      There  wal 

Lk";i  :"^":?   •'"  "'^^  ''''■     ^^  «"'"•'   "--  ^^"  ^he  musses 
'  <1)  and  uas  able  to  get  up  and  stand  on  his  legs  if  he  took  time 

I  he  sensation  was  perfect;   the  knee-jerks  present,  perhaps  a  little 

^l^gera^d;  no  ankle  clonns.     The  feetand  ankleJ^ere  ,!erspir!^ 

ed) .     No  swelling  of  the  articulations,  and  no  pain  on  pressure  of 

01    ns  left  SKle  he  demurred  very  much,  but  gradually,  and  apparentlv 

.  a  great  deal  o    difficulty,  he  got  himself  over.'    The  llgs  could 

hen  be  momi  easily  and  freely;    no  pain  about  the  hip  joint,  and 

0    eel      be  flexed  and   extended   readily.      The' spine' was 

straight,  the  lower  dorsal  vertebrae  a  little  prominent.     xNo  tender- 

lower  lumbar  and  sacral  regions  he  was  sensitive  at  a  distance  of  an 


I 


I:  I 
1 1 


78 


WiUiavi    Oder. 


[78 


inch  and  a  half  or  two  inches  from  the  middle  line  and  mrf,".  i    i 

There  were   „„   ,en.,ory  d,a„ge.,  „„    l,e,„i„„,esthe.ia,  „„    l,e,„i 
a  .ops,..    The  ,,a,ie„t  ,„,d  that  hi,  chief  trouble  was  „,o  e  Z     e  d 
"I  i>mv,„K,  lest  ,t  .ho„|d  ea„se  ,,ai„,  than  any  pain  it„|,     t 
'lavs  ngo  he  sat  „p  iV,r  „  «„„,*,  ofhours,  ..„>  "I  o^be,  h         „    "T 
sat  on  the  Cai,  b,.t  fe.t  ver,'  tired,  and  .ireae^^asl'^^    "'::;' 

to  H,!  r,  "^ '•"■'"'  """"'"'''°  "'"'  "'<=««"•«">•.  ""-I  the  I'aqnelin  eanterv 

^:«nr.e  ut^ri'dtr'"""  "'™""-^-  -" "-" '-  »^'  '"• = -«- 
.^:afe,,rps,^ii-i-,t;-b 

d.t.on       No  pain  ,„  the  back  :  feels  a  little  stiff;    knee  Irks     ' 
normal  ;  condition  good.  >    '-nee  jeiks  an> 

Cases  II  and  III  in  J)r.  Gihney's  paper  arc  very  nn.ch  lil-n  H 
one  he.e  mentioned,  particularly  i„  thl  fLt  that  t^^^        ,     ^  ,  ^ 
^-d  after  convalescence,  and  in  both  instances  the^e  w  ^     sMu 

^nr;."7rr-'"rf^^''^^-^"^  *«'"-' -d  -  -other 
m  en    .  '  "'"''  ^^^•'^'"'^^-     ^°  ^''«  -««  '-ported  here  Z 

pat  ent  also  lays  a  great  deal  of  stress  on  the  jar  which  he  re  civ  e, 
b    the  sudden  jerking  of  the  cable  car.     In  b^th  of  those  c  ,s' Tt 

^:;':;i%;;;;i:^-^^^^ 

An  explanation  of  the  symptoms  in  these  cases  is  bv  no  means  e..v 
As^^ ready  ment.oned    Dr.  Gibney  regarded  the  i;sion  T      ^  : 

mX^^!       :r     ^^'''""'''  ^^-^*^^'''  '-d  -'th  this  view, 
ro!  t     T         1"^*'^*'0"  g'^'^"'  I^r.  Pepper  seen,s  to  agree 

typhoid  fever,  but  the  symptoms  do  not  usually  develop  (as  in  throe 


or  four  of  i 

oence  has  1 

the  stern  u  I 

to  suppural 

disappear  v 

protracted  | 

suppural' on 

as  are  descj 

in  the  s'jcon 

simple  perif 

puration.     ] 

patients  was 

be  very  illoj 

same  cau8c,  3 

simply  of  the 

and  anaJogoii 

spine"  and  ti 

have  pains  01 

the  second  ca 

was  that  of  a 

a  leg— even  t 

yet  in  a  few  n 

the  slightest  ij 

I')  scream  out, 

sure  could  be 

in  a  few  days 

iucoii.sistent  w; 

I  have  recen 

but  which  I  th 

neurosis. 

Case  III.—^ 
Nov.  2nd,  1895 
Family  history 
insane. 

He  was  ner\ 

excited,  and  hac 

times;   never  h 

iilcohol,  but  is  n 

September  23i 


79] 


The  Typhoid  Spine. 


79 

or  four  of  the  cases  hero  described  1  .f  .    . 

cence  h.s  been  well  established     Th  '^.''  '""'  "^^'^^  ^«"vales- 

^J'e  ster„u.n  .nd  the  ribs,  proceeds  .r""?''^;  '''"  "'^^'"'^^  '^^«"* 
to  suppuration.    I  have  in  s  ver  ]  il;         '"'''  '^"'  ""^  "ocessarily, 

<i'-ppe.r  without  suppurat^rw:^:::;r'''"r'''^^ 
protracted  periosteal  thickening,  1  stin  "r        T'  '''  '""  "^  ^  '^"-^•' 
«»;>;>t.r«</o»  :  and  it  is  difficult  to  co  ,    '       VT'^'  ''  "^""*''«'  "''^/'-'^ 
as  are  described  in  the  se       d    ,    Tinl  c^'      ""f^^  "^''^"■"'«-^ 
.n  t[.c  second  case  which  I  here  r lit       ?   "  !     ^''-  ^"'"^>''«'  «»d 
-»P)o  perispondvlitis  u  lucr  „!';"''  "  '"-^'-' ^»->  f,  . 
Purat.on.     In  both  of  „,v  ,,ises  ZL        ,"'""''  P"'"'^^  ^^"  ^o  sup- 
patients  was  that  they  wer^  n        sthef  ""     Z'";"""""  ^'^'^^  »'>'  the 
^^-  very  illogical  to  Lsun.e  thT       of  ,1  "  '  ''"""■^^'  ^^  ^-"'^ 

-- -use,  yet  I  cannot  hel^n:^.:  '"^^^"f-  -«  ^ue  to  the 
-jply  of  the  painful  neuros  s  ^„  Si v  plr""" '^  /'""  areexan.ples 
and  analogous  to  the  painful  condiT   '  ""    '^''"^^  n-ritation," 

;P"-"  and  the  "railiy^L^^t'^^™^.  ''t .'"  ^'^  "  ^'^'^'--' 
J'ave  pains  on  the  slighLt\noJl''.r  u  ','''  ^''^'  '^^^'^^  "^av 
tl.e  second  case  reported,  th:  , ^  h  v ^  ^'  "^  ^  "^  '^^^^  ^" 
was  that  of  a  hysterical  patient-  thu  ,  ."''"^  '*'"'  «™inatio„ 

aJog^eventheidea  wal  o,"!gh      "   r^;      "'  ^''"'^  ^^  ^'^"^^ 
yet  ,„  a  few  minutes  he  lifted  it  hims.l  "  "^'"'"^■"S  Pain,  and 

t'-'  .slightest  pressure  in  the  u  d  ,  -r"^  ^"^  '"*  '''  ''^*'-  ^o  also 
to  scream  out,  but  while  his  atten  /  '''"^^5>«»«  would  cause  him 
«-  couhl  be  nude  with  d.,:;  r^,'''''^^'^^''  elsewhere,  pres- 
'»  ='  ^-  <'^^ys,  with  disapp  a^  r  tn  tf  ''''  '''''  ''^^^^y 
--..s^stentwithacl.ronii  H>risp:  dvi,-'  ''"  '''^^^''^^>  '«  ^-^e 
1  have  recently  seen  . I  ^'^'lus. 

insane.  »  "" '  ''"'""•-  '■"%';  »no  sistor,  however,  is 

lit!  was  nervous  as  a   bov         l 

e.«i>cd,„,Kii,„,i  ..,„.„„„,„;,'"   511°,"'"'"'''°  "■■■•"  """=''  "I'™ 

'i™»;    "ever  l,ad    |,„,.  :,„ku,n.,,A  ''"'"''^""'  ""■««  «'  f"" 

•"» '-"'  is  no.  a  hard  dH„;;;:     '""''  "■'"■'""  '•'•  '"■'-'■     Take, 

S...e„..er  .3rd,  >S9:,,e had a„a„aek„n,p..d,ver  of  „„„.„, 


80 


William    Oshr. 


[80 


severity,  with  prolonged  dcsliriiim,  extensive  bed-sores,  and  very  .^r, ,u 
prostnition.     Convalescence  was  not  cstabli.shed  until  January  lOtI, 
1892.     During  and  after  convalescence  he  was  very  nervous,  !ui.! 
had  uneasy  i)ainH  in  the  le-s,  his  feet  were  tender,  and  he  tired 'v(,v 
easily.      He  had  no  pain  in  the  [)aclv,  no  soreness,  b„t  the  tendernc-'. 
in  the  feet  and  nervous  feelin-s  persisted  for  six  or  ei-ht  months  ait.  r 
convalescence,  and  he  does  not  think  that  thev  have  ever  entirely 
disappeared.     He    attended,    iiowever,  to   his    business,   gained   i„ 
weight,  and  felt  pretty  well,  though  never  entirelv  free  from   nne-.M- 
sensations  in  tlie  feet  and  legs.     In  the  spring  of  this  vear  th. ... 
symptoms  increased,  particularly  after  some  sprees.     He  had  neur- 
algic pains  in  the  legs,  and  he  felt  weak  and  unstrung,  and  evi<lentlv 
got  into  a  very  nervous  (condition.     He  had  a  dread  of  walkin-^  au.l 
could  scarcely  force  himself  to  go  as  far  as  the  corner  of  the  street 
He  slept  badly  and  got  into  a  state  of  extreme  neurasthenia.     There 
were  twitchings  of  the  muscles,  and  the  feet  and  hands  felt  numb,  an.l 
he  complained  that  when  his  shoes  and  stockings  were  off  therci'  was 
a  smooth  feeling  as  if  something  was  between  the  feet  and  the  Hoor 
At  this  time  a  doctor  in  New  York  suggested  there  was  oncoming 
spinal  trouble,  and  stated  tluit  in   testing  the  sensation  ov-r  the 
spine  with  hot  and   cold   water  he   could  not  distinguish  between 
them.     He  ordered  him  electricity  and  massage  and  general  toni.s  ■ 
for  the  past  seven  or  eight  weeks  he  has  not  been  at  work  and  imJ 
impioved  a  good  deal. 

Present  ComUtion.—TaU,   able-bodied  man;    looks   a   little  pale- 
gait  is  normal;  not  spastic;  station  good;  no  Romberg  .symptom' 
no  atrophy  of  the  muscles ;  legs  scarcely  in  proi)ortion,  however  to' 
the  rest  of  the  muscular  development.    The  spine  is  straight,  nowhere 
painful  on  pressure,  no  special  prominence  of  any  vertebra.     Sensa- 
tion is  everywhere  good,  no  retardation,  distinguishes  easilv  between 
heat  and  cold.    He  thinks  that  about  the  feet  and  ankles  the" sensation 
IS  a  httle  blurred  and  unnatural.     He  feels,  however,  a  sharp  poim 
and  distinguishes  readily  different  objects,  and  the  thermic  and  pain- 
ful sensations  are  unaifected.    He  has  no  abnormal  sensations  al..M,t 
the  back  and  abdomen,  and  has  not  any  sense  of  constriction  or 
girdle  pain.     There  is  no  vaso-motor  disturbance.     He  sweats,  how- 
ever, easily  and  the  hands  are  clammy,  and  he  has  had  at  times,  ho 
states,  marKed  blueness  and  congestion  of  the  feet,  and  they  are  olt.n 
cold  in  the  morning. 


81] 

The  refl( 

left  side,  an 

are  normal 

F'lpils  are 

normal;  th 

The  exan 

Here,  aft 

ilelirium,  s( 

pMtient  had 

t"ni8  diniini 

'bsa])peared, 

i/.cd  bypron 

described,  th 

sation    of  w 

iesion;  (2)  n 

evident  that 

it  would  scei 

(late  of  the  fe 

iier  does  the  i 

man  insists  tl 

present  durinj 

siil)sequently. 

muscular  wea 

nttaekoftyph, 

ill  the  paper  h 

lie  refers  to  tin 

lifter   tyj)hoid 

enfeebled  cond 

!iii<l  sometimes 

"ulking  long  d 

■studied,  but  it 

'K'ld  of  defect! 

iKTvous  centres 

general  appeara 

typhoid   fever. 

iiiicoinmon  sym 

reflexes  are  not 

'  Transactions 


The  Typhoid  Spi„c. 


81] 

-'"=   ^ypnoia  iSpiiic. 

ol 

The  reflexes  are  hicrcasfd-  kiu.,.;,,. I 
'^■<t. side, and  a  slightankleclom,  1,;       '/'''''  I''^''*'«"''»-Iy  o„  the 
arenonnal.     Ti.e'e  is  .fZ^'i'T'-   '^^''-'^i"  reflexes 

-nnal ;  there  is  no  restriction   ,f  tho  !i.  ^L,  ,   '''  '''^'^  '''^'^•■^  '^^e 

'i<''-."um,  severe  nervous  sy„,,toTa;  d  1  '■"''"'^  '''''''  ^-^^* 
-t.ent  had  disturbed  sensations  h  th  ^17  '.T""'""'"^'  ^^'^ 
->«  dnn,„ished  some^vhat  within  fiv.  !  ""^  \'^''     '^^'^  «>■»»}> 


';:-  diminished  so.;vi:;r  r    t  r^  ^""  ^^^-  -''- « -p- 

<''«;]>P-re,I,  and  reeurred  with  inten  i      T  ' """'''•^'  ""'"'  ^"^'-'.^ 
->  b)'l.ronounoed  neurotic  n,a  Si  '''^^^-f  'T'  ^'--^- 


i->  ^>'Pro,K,unced  ;:  :,:^:!;^-;>-  '^'^^.^  i'-d  chara.;. 
^i'-ibed  there  were  no  pai  J  '  t  td- or  f  "'  ''^  ^^^^^^  ^^^-^• 
^''t.on    of  weakness.     The  sv,„„t«I  '''^""'"'  '*"'.^'  '^  ««n- 

i-ion;  (2)  neuritis;  or  (3)  a^  el^s  "S'"' i  •' ' ^  "'"^^"'  ^«'--l) 
-Klent  that  the  doctor  n  att«  Ze  f  7  '"  ''^'^^^^^  it  was 
it  ^vould  seen,  that  the  pati  S  tnd  f "  '  ''"^''^^  "^^^'^^-"'  ^ut 
<lato  ofth<.  fever,  would'spe^r;  ;  o:l""^*"•«  >--  ^-m  the 
■•'»•  does  tl,e  case  conform  i„  its  l^^fX  "'''"■^'  '''°>'  «"^h  view; 
-an  insists  that  the  same  fee  its  w"  1^'  *"  "  """'■^'^-  ^^^'e 
I>resent  during  the  convalescence  fi^/r  f  ,"""  '"  ^''^  ^'^^^  -- 
-'-q-ntly.  There  did  no.  a  >pt  o  .l  l  ""'  '""''  "'^"^'^'^ 
'""scular  weakness  such  as  sometimps  ,  """  ^'"O' «Peeial 

='ttaek  of  typJ.oid  fever  witho  t  ,  ™  1  '  T'  "'^"  ''  ^''^''^^^^^ 
J"  the  paper  by  Dr.  Georgv  1  s  '  vT-  ''  ''"■'''''"•'''  "^'"-tis. 
He  refers  to  these  cases  in  the  fb  lowilr  ''','  "''"  ^^•^''''•"'^  ^^^^r* 
'"■t-  typhoid  fever  of  conscW  bit  '  "  "''  ''^  "^*  ""•--' 
enfeebled  condition  of  tl,eh>we^^^.^^^J^^^^^^  *°.«»^  "  deflnitelv 
aml  sometimes  a  person  never  eUr  ^  ^'"'"'"'^^  ^"^ ''^"'"^  ti'^'^. 
-  <in^  long  distances.  Such  ^  r  c  ^^sr ""  ^'^  ^P"-^'  ^^ 
*Hi.ed,  but  it  is  probable  thev  wo  IdTf  ".  "'""'''  ^'""  '^'"^^y 

'-ad  of  defective   innervation   fh>n    ;',"•'  "  ""''  ''^^  "-'-  '»- 
""rvous  centres."     InthecnsenT    !'''^«"g^^d    ^^xhaustion  of  the 

^-al  appearance  of  the  p^io^ ""i;';:^:^;:'  ^'^  ''''^''  ''''  ^^- 

pLoHl    fever.      The  para^sthesias'st":     I    r'-r!,'^''"^''"^ 

""common  sympton.s  of  neurastheni  i     ,  ^'"''^'^"'''^d    are  not 

-fle-xes  are  not  at  all  infrequem  '  '"  "'"'^^  '^'^  --"ggcrated 

'  Transactions  of  the  .Association  of  4meri.^„  P,     •  ■ 

-imericn  Physicians,  Vol.  lil,  i888. 


i   i 


i  x 


82 


WiUiarn   Osier. 


[82 


i ' 


It  is  not  unlikely  that  under  the  designation  of  "typhoid  spine" 
Dr.  Gibneyhas  described  several  distinct  affections,  and  T  would  not 
be  understood  as  holding  that  there  may  not  be  a  perispondylitis. 
Nor  indeed  are  all  the  i)ainf\il  backs  in  typhoid  fever  neurotic;  thus, 
a  patient  recently  under  my  care  (Hos.  No.  80-19)  n-as  admitted  in  an 
attack  of  moderate  severity  about  the  end  of  the  third  week,  the  tem- 
perature falling  to  normal  by  the  26th  day;  then  after  a  period  of 
apyrexia  of  seven  or  eight  days  he  luid  a  wfll-markcd  relapse  of  about 
two  weeks'  duration.  During  convalescence  he  began  to  comjilaiu 
of  severe  pain  in  the  back  of  the  neck,  and  at  the  attachment  of  the 
muscles  of  the  occipital  bone.  There  was  no  actual  tenderness  in  the 
vertebrae,  and  movements  to  and  fro  and  lateruUy  were  not  associated 
with  any  very  great  pain.  An  application  of  the  Paquelin  cautery 
relieved  it  for  a  few  days,  and  then  it  recurred.  The  examination 
from  the  pharynx  was  negative.  The  condition  persisted  for  at  least 
two  weeks,  and  while  at  first  coniincd  to  the  neck,  subsequently  he 
had  soreness  and  stillness  of  the  back ;  he  walked  stiffly  and  lield 
himself  very  erect.  He  says  that  it  is  better  when  moving  about 
than  when  lying  down.  No  special  tenderness  in  the  spine,  and  no 
sharp  i)ain;  no  increase  in  the  reflexes;  no  indication  of  neuritis. 
He  gradually  improved,  and  when  discharged  he  was  very  much 
better,  having  gained  11|  pounds  in  weight. 


TYPH( 


From  the  Joh 


C^  X  u.  \/^ 


TYPHOID  FEVER  IN  BALTIMORE. 


By  WILLIAM  OSLER,  M.  D. 


From  the  Johns  HopJcim  Hospital  Reports,  Vol.  IV,  No.  1,  Baltimore,  Md. 


Vlil.-TVI'lIoii)  FK\  i;i{   IN    I'.M/n 


.MoiM-: 


BY  WILLIAM   OSLER,   M.  D. 


AiiH.ii<r  the  I'itifswliicl,  still 


vr)mi<r  lives  t(i  (lie  .Miiiotiuir  ofinl 
liijrli  ninlv.   Tliopityoliti.-.t,,,.,  ti 


pav  an  mn 


(•(■tlOII 


-ai'v  Dcliaii  tril.iitc  of 
i-fS  JJiilliinorc  IjoM.s  a 


.flivc,s(L'2Slfor]S92,ii„ti,„.li„l 


aiK'c.      1" 
las  boon  prcaelnMl— wlictlicr  tlio\ 


lat  tliis  annual  saci'iliccdl't 
iii.u<''iiiMiiii|)li()ii).  is  not  due  f 


or  nioi-c  thai,  liliy  years  tins  <.„s,„.l  of  prcv 


i'MisaiKls 
n  imntr- 


■ar- 


111  tiiccars  nfcoMiicils  and  corpora t 


f'orbc 

cjjir'iciithi  (IcHir/nril  an, I  (frHnail 
■incidence  of  iiijW'doiis  diiicdsrs ;' 
proper  imhitiim  of  tlic  sir/:.  Of 
liaitiniorc   lias  a  \vc 


would   licar  or  whollier  ll 


•'iitive  inodicino 


K'v  would 


ions:  that M 


7  carrii'tl  out,  /nl 


llCf    to    (I 


'lire  ni('(tHurr/i, 
niinitnuui  the 


:,  imrc  tr<d,r,  f/ood  ilr 


sanitary  essentials  i 


'innf/r,  (1)1(1  (I 


un 


I)roteeted  sources  and 


•arran<,a'd  water  supply;  still     1 


iiotliini;  else — no  se 


constant  liability  to  containi 


11  a  modern  town, 
liowever,  with 


no  hospital   for   infeetious   d 
such  a  disease  as  typhoid  fo 


wan-e  system,  no  system  of  isolat 


nation.     Jt  has 
ion  of  the  sick. 


of  street-waterini 


iHcases,  no  compulsory  notification  of 
vor,  no  disinfeetinii'  station,  no  system 


The  streets  are  cleaned,  but 


no  iiisj)eetion  of  dairies    i 


year  the  citizens  brcatl 


so  carelessly  that  for  a  1 


,  no  uisj)eetn)n  of  meat. 


of  all 


sorts. 


10  a  mixture  of  air  with  h 


largo  part  of  the 
Di-se-dnnLr  and  filth 


Perhai)s  the  best  ra 


u< 


found 


io  of  the  sanitar 


ni  the  mortality  returns  from  tyi)hoid  fe 


y  condition  of 


a  city  is  to  be 


iver. 


TlIK    IXCIDENCK    OF    Tvi.,IOt,)    Fkvku    IHUUSU    TllK    Vly,' 

Vkars  1888-92. 

To  the   deaths  from  typhoid  fever  have  been    added    the   cases 
eturncd  as  typho-malarial  fever,  since  no  reason  now  ren.ain!  f 

parate  class,f.catn>n.     We  nu.y  speak  for  this  latitude  with  so 
onfidence  npon  tins  point,  after  a  study  of  son,e  300  cases  of  typhoid 

1,1893,  there  had  applied  for  treatment  at  the  Johns  Hnnlnn«  n        .  /"/"^'""i'' 
cases  of  malarial  fever.    Thesn-calM  fvp!  o, naiad     f'  '    ''  "'*'"  """^ 

fever  in  the  Boston,  New  York,  und  Ph^lI^Il^S::'       "  '^  '""''^'  "'''  ''''^^' 


urns. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-S) 


7 


// 


{/ 


:<°  c^ 


.<? 


IC^'r 


^/ 


LO 

1= 

11.25 


■-  illM 

|50     ™"= 


M 
18 


R  11.6 


1  ilUlUgLaUlilLi 

Sdences 
Corporation 


0^\ 


iv 


<v 


^\ 


^ 


Is 


23  WEST  MAIN  STREET 

WEBSTER,  NY.  14580 

(716)  873-4503 


^    <^3^ 


r 

o 


'^ 


^ 


\\ 


^N 


KJO 


Williiim    (hi,;: 


[U5U 


Accord  ill  o-  to  the  licaltli  reports  there  were  in  1888,  202; 
-M;  ill  1,S!K),  ;;01;  in   IStll,  189;  and  in    18i)'2,   22(5   deaths  f; 


in  ?S,S!i 


typhoid  fever,  a  tot.,1  niortalitv  of  114( 
229  eases.     Tl 


4(i  eases,  a  veai 


'OIII 

averati'e  di' 


le  niorl)i(iitv 


tiu 


total 


nMnH)er  of  j)ersoiis  wli 


not 
re<iistrati(,ii 


IS 


ni 


liave  had  tiie  disease,  eannot  be  determined,  since  tiio  cases  are 
re|)orted  to  the  iiealth  otliee;  and  unless  the  system  of 

exceptionally  uood,  a  more  reliable,  thoiiiih  probably  low  estimate 

ay  be  made  by  pnttinj;-  the  average  death-rate  at  i'rom  12  vo  IT)  p,.,. 
cent.,  which  are  very  moderate  figures.  Taking  the  death-rate  o|'. 
say,  12  ])er  cent.,  this  would  give  at  least  13,752  eases  of  tvphoid 
fever  during  the  five  years.  Approximately  for  the  five  ye;irs,  the 
average  of  fatal  eases  would  be,  estimating  the  census  at  4.")0,000,  a 
little  over  5  jicr  10,000  of  population,  or  an  average  annually  oi'~ 
on  the  above  statement  of  morbidity — oiu'  ease  of  typhoid  fevc  r  to 
every  IChi.i]  inhabitants.  Compared  with  the  three  other  large  cities 
on  the  Atlantic  seaboard,  we  find  the  following  for  a  corresponding 
period  of  five  years: 

Boston,  ■  802  deaths,  a  yearly  av 
population  at  about  442,000  (averaj-e  of  the  five  years)  giv 
of  ;].{)  per  10,000  living;  and  estimating  the  morbidity  as  above,  an 
annual  average  of  1!)24  cases,  1  lo  about  every  229  of  the  inhabitants. 


erage  of  100.4.      Estimating  the 

es  a  ratio 


New  York,  i   1897  deaths,  a  vearlv  aver 


IIU'C  o 


f  379.4.     Kst 


imatiii' 


tl 


lb 


the  i)opulation  at  about  1,700,000  (average  of  the  five  vearsl 
would  give  a  ratio  of  2.2  per  10,000  living,  and  estimating  the  mor- 
bidit 


y  as  above,  an  annual  averaue  'W  4552. 8  cases.  1  to  about 
:.ftl 


everv 


le  iniialiitants. 


IMuladelphia,;;  330!)  deaths,  yearly  average  ()(il.S.  KstimatiuLi 
the  popidation  at  about  1,000,000  (average  for  the  five  vears),  tin- 
would  give  a  ratio  of  '.iJ'il  |)er  10,000  living,  and  estimatini>-  tl 
niorbiditv  as  above,  an  annual  average  of  7941. (!,    1    t 


lie 


o  aliout  cvei'v 


125.09  of  the  inhabitants 


Th 


e  ward   map   published   in    the  City  Health   iJeport  for    LSI 


gives  the  greatest  number  of  fatal  eases,  and 


one  may  suppose  the 


greatest  ])revalence  oltlie  disease,  in  the  outlying  wards  of  tl 


moi 


'c   particularly  in   ward    1,  which    has  the   highest  ti 


"lire 


le  citv, 


\vai'< 


'"  Ileport  of  Uealtli  I)e|mrtmeiit,  page  8,  1892. 

IFroiii  lii,'iiv(>s  Uiruily  fiirnislied  liy  Eiiirnoiis  Clarke,  Secretary  of  the  lioiinl  of 
Health. 

i  Report  of  Health  Oepartmeiit,189'J. 


ironi  which  thcv    amc"       From  tl„>    v    ,"•""""' to  tfic  wards 
Baltimore    Countv  n,    i "  \        "  •.  ^^7  ^^^^  ^"^  -- =   ^-n. 

caoe.     Of  the  ca...  in  the  c   v  w  i  J         u  ."T '  '""^  ^^"''™-^'  ^ 


»">li'  ■n.ich  remains  to  learn  ■ilmnt  th„         r. 
^•'^"'■■^vand  f^rowti,  o<'thetv„h  i  ■        """^''^'""•-  ''^^orin.^-  the 

.<n.ral  ,aets  relating  r'-'r"""  '"''?'''^  ^'"'  •'•'•'^•'  -^-" 
fre„.en,  transmission  hv  d!  •!:.,:;:  -" -^=!'>'-'-l  =  vi.,  its 
Tith  defeetive  dr«;„ "  ...  .,     .  "       '\'       ^'"^   :.itimate  eonnection 


— ection 

--ln,tally  eontaminated   l.v  .l,;';:;:::;""  '^' '"^''^' ^l""''  -  """<- 
'ii- these  factors  are  at  uorl-"  in   .  ■'  "'  '"■•'•^"  ""T'i^v  I'ow 

i"*u.eoroneort;::::  :  ;;;:;;::;^;\'^^^^ 

(0)   The  I(Wn-,s',W,_  „  '.''""'•''" '^'  "'" '"<«'t.ons  .liseases. 

...alitv.     In  the  ant.    ^      1        J h^'"""  T  "' --l'^'<-'ib-  .ood 
during  the  present  ve-.r   hot  r  "'"' ••^■^"•^'^"rs  are  low,  as 

onsl,tonta!ninat:,\:;;h     :.;•;:  ;;:r"-^-'-f^  ^^!  '>^"  <^an,er- 
-alysi.  can  he  made,  as  th^  F    ,  ;.    ^  '  '''''T'''  '"•'"«'-' 

skilled  haeteriolo.eist.  '"^  ''  '"'^  '"'•"'^h"^!  ^vith  a 

The  distribution  of  the  disease  indiffi.rentlv  in  ..11  .         . 

I'^'vailing  n,orc  in  the  area  supolied  t  !     v'  '''.'"''''  ^  ^"^'' 

l-v-"ving  <iistrictsofw-ardsluXVr      1       ''""'■  ""'  '"  ^*" 

'''-V"f><'^"ot  in  large  eonte;;;lr:;l;;;~rr'"^^^^ 
vo  freedom  of  the  hi.dier   Ips«  L.     i  a  '  comj.ara- 

1         .  "'h"^"i  less  crowilcd.  n-.rts  nf  fiw>  ^^ 

*"  ""■"  '^"■'-"  "■•™ " ' .".  '..■  .:i:::;i,;:';;r;;;.'"sc' 


ti 


102 


W'illiaw    Os/,r. 


1(1 


thewntcr  alono  responsible,  tlim;  woiiid  liave  boon,  in  areas  supi.bV,! 
by  OIK  or  other  of  the  streams,  e])i.lomics  of  wide  extent,  siul:  as  hav.. 
been  described  in  otlier  cities  with  a  double  water-supply.  Xeitl„r 
streaui  is  tree  from  suspicion  while  so  many  possible  sources  of  pollu- 
tion exist.  Typhoid  ft;\er  has  prevailed  extensively  in  areas  drained 
by  Jones  Falls,  particularly  in  Towson,  in  LuthJrville,  and  about 
Pikesville. 

In  the  sanitary  history  of  cities  it  has  been  amplv  denKmstrattd 
that  an  abundant  and  good  water-supi)ly,  though  „f  tiie  iirst  imp.,rt- 
ance,  is  not  enoufrb  u>  reduce  tin'  death-rate  from  typhoid  fever  to  ;. 
ininimuni.      In  j.altimore  the  deaths  from  typhoid  "fever  per  1(),(KI0, 
prior  to  1875,  ranged  from  7.4  to  8,  and  sinJe  the  introduction  of  th' 
water-supply  the  rate  has  been  only  from  o  to  (3  per  10,000.*     It  is  to 
be  remembered  that  this  rate  is  not  correct,  since  deaths  from  typlio- 
malarial  fever  have  been,  in  all  the  late  returns  at  anv  rate,  exclialcl. 
There  are  several  remarkable  instances  which  illiisinite  the  persist- 
ence of  high  rate  with  good  water-supplv,  but  it  will  be  sullicient  t.i 
quote  the  city  of  Dantzic,  in  which  the  new  water-works  were  com- 
•    pleted  in  1869.     The  high  death-rate  from  typhoid  fever  persisted 
until  the  introduction  of  the   sewage  system,  after  wliicli  it  fell  thm 
an  average  of  <).<>  per  10,000  to    l.r,  f„r  the  six  years  eu  "  v  JS.S-l. 
The  same  is  shown  in  Stockholm  (to  be  referred'to  hm  wliich 

the  dciith-rate  froia  typhoid  fever  fMl  pari  pa.s,'^u  with  the  i.Ntension 
of  the  sewage  system. 

An  important  liictor  in  certain  wards,  particularly  in   the  annexed 
districts,  is  the  continued  use  of  well-water. 

It  is  possible  that  the  virus  may  be  spread  widelv  throng!,  the 
water,  not  in  liosage  potent  enough  to  cause  ihe  disease,  excvpt  in 
very  susceptible  persons,  but  in  the  preseiu'e  of  favoring  comlitions 
capable  of  rapid  development.  Thus  one  or  two  tvphoid  bacilli  in  a 
glass  of  water  may  be,  probably  often  ar<.,  taken  with,  impunitv  bv 
an  individual  not  specially  sus.'eptible,  but  a  tinv  in  water  used  to 
rinse  a  milk  can  or  Jug  would  find  in  the  milk  such  a  suitable 
medium  for  growtii  that  in  twenty-four  hours  the  food  would  be 
highly  infective. 

(/>)  DefeHive  JJrninar/e.~Thv  influence  of  defective  drainage  on  the 
incidence  of  typhoid  fever  could  not  be  more  clearly  shown  than  in 

•Ei'wiM  F.  Stnith:   T?ie  Influence  of  Sewerage  and  Water  Supply  on  the  Ikalh 
Kate  in  C'ltie.i,  [iii^je  140.     Lansing,  Mich.,  1886. 


llil! 


163] 

tlie  annexe 

trastinj^  se' 

;i  filtli  (li.soi 

.'inv  local  it; 

the  inhabit 

trreater  tiie 

tics  that  th- 

produce  an 

the  deaths  1 

in  the  very 

nearly  doul 

Admirabl 

only  siirliict 

are  collectei 

most  part  ii 

from  70,000 

(iC  the  city,  v 

tinht  are  noi 

occurs  in  a  ' 

vicinity.     Fi 

sewage   and 

grooves,  j)a.s 

houses,  cons: 

polluted  to 

rliflcrent  loci 

out  than  the 

typhoid  fevei 

ulone  sufficie 

the  soil,  pari 

rcruarkahle  i\ 

strikingly  sh( 

(I'll  step  l)y  St 

fiilling  from  ] 

8937  metres  ( 

40,435  metres 

65,709  metre? 

been  almost  a 

Prof,  von  Zie 

the  hospital  1 


163] 


Typltohl  Fern-  in   naUimorr. 


163 


he  annexed  chart  fron.  Dr.  S.nith's  article,  aln.adv  referred  to,  eon- 
rastn.,.  sewered  and  unsewered  t.nvns.    Typh,>id  fever  is  essentially 
..  filth  d  seascand  ...the  words  of  Liebenneister,  '<the  disposition  of 
-y  loea  ,tv  to  an  ep  den.io  ,lepends  lar.elv  on  the  exten     to  which 
the    nhub.tants  breathe  or  drink  the  contents  of  their  privies-  th 
jrreater  t  e  chances  of  this  are,  so  nn.eh  the  ,reater  arc  tile  prob^biii- 
t.c.  that  the  introduction  of  an  imported  case  of  tvphoid  fever  will 
p.-oduce  an  ep.dcnie."     Tn  JJuda-Pesth,  von  Fodor  has  shown  that 
tl.0  deaths  Iron,  typhoid  fever  per  100  luM.ses  are  more  than  doub^ 
...  the  very  d.rty  houses  than  in  the  very  clean,  and  in  the  san.e  wav 
..-.r ly  double  per  100  houses  when  the  yard  was  verv  dirtv 

Admirably  situafd  for  natural  ,lraina,<,c,  Baltimor<:  i.as  praeticallv 
only  suriaee  sewerage,  from  which  the  rain-water  and  kitchen  outHow 
ure  collectcHl  m  sewers.     The  ex,reta  (urine  and  fioees)  pass  for  the 
most  part  into  privy  pits,  of  which  it  has  been  estimated  there  .re 
fnm.  .0 000  to  80,000,  occupying  one-twentieth  of  the  J^Z^^Z 
nl    1.0  city,  exclusive  of  streets  and  parks.     Many  of  these  when  water- 
tight are  not  a  source  of  special  danger;  but  unqucstionablv  leaka-n- 
omirs  m  a  very  large  number,  with  saturation  of  the  ground  in  the 
vHHi.ty.     r,,  addition,  the  arrangements  for  removal  of  the  surface 
sewage   and    kitchen    waste    are   such    that   in    the    shallow    brick 
IjrooveB,  passing  usually  in  the  little  ,,assage-wav  between  adjacent 
houses  constant  soakage  takes  place  into  the  earth  beneath,  whic-h  is 
|K>  hited  to   a  very  considerable  depth,  varying  very  greativ  with 
rh  k.ent    ocahties.     No  single  fact  has  been  more  ck.^lv  bi-ought 
out  than  the  intimate  association  between  sewage-polluted  soil  and 
tvi.ho.d  fever.     As  already  stated,  wholesome,  healthv  water  is  not 
'.one  sufficient  to  abolish  the  disease;  but  healing  of  ihe  sickness  in 
the  so.l,  puntying  it  by  proper  drainage,  is  at  once  followed  bv  a 
.vn.arkable  fall  in  the  death-rate  fron.  typhoid  fever.    This  has  been 
strikingly  shown  in   many  cities ;  thus  i„  St<,ckholm  the  mortalitv 
•     step  by  step  with  the  increase  in  the  number  of  metres  of  sewers 
a  Inig  fi^m  1877,  with  a  mortality  of  5.1  per  10,000  inhabitants  and 
8  .J.  metres  of  sewers,  to  3.7  per  10,000  inhabitants  in  1883,  with 
40,43o  metres  of  sewers,  and  to  1.7  deaths  per  10,000  in  1887,  with 
o,.09  metres  o  sewers.     I„  Munich  and  Vienna  typhoid  fever  has 
been  almost  abolished,  and  three  years  ago,  when  in  the  former  city. 
Pro  .  von  Ziemssen  stated  to  me  that  the  reduction  in  the  cases  in 
the  hospital  had  almost  changed  the  character  of  the  service 


and 


\\\\ 


'•r 


I«U 


\Vi/liiim    Os/c.r 


[Ifil 


tlioy  had   soiirccly  piiticnt 


cliiiiciil  courses. 


The  i 


s   ciioiio;!!   to  illii.stnilc  the  disease  in  tii 


I'll 


res  lor  .Mmiicli  and  \' 


l)een  (|iioted  that  it  is  not  necessarv  to  ref 


ienna  liave  so  oft( 


er 


to  ti 


leiii  nil 


■ther  tl 


'71 

'v,m  Id 


0  to 


State   that   the   deatiis   per   10,000  living   have  fallen  from   12 
between  1  and  2. 

Tiic  loeal  conditions  perniittinj.'  tlie  disease  to  l)e  endemic  throimh 
out  the  year  relate  Mncniestionahly  to  the  persistent  pollution  of  U,, 


soil 


\Vh 


le  cases  of  ty])hoid  lever  occur  in 


tially  an  autumnal  disease,  and   th 


ihieh  at  this  season  renders  tl 


every  month,  it  is  essen- 
ere  is  a  factor  as  yet  unknown 


iikelv,  favors  i 


le  ])oison  more  potent,  or,  what  is  n 


factory  explanation  has   vet  b 


n  some  way  its  urowth  and  distribut 


ion. 


N( 


Hire 

■iitis- 


een  uiven  of  tliis  autumnal  prevalence 


certainly  one  of  the  most  striking'  fiicts  in  the  natural  historv  ol 


lisease.     After  the  heat  of 


th 


su 


when  the  streai 


lauier,  partieularlv  a  hot,  drv 


and  with  it  a  proportionateb 


us  and  ponds  are  low,  the  drainaue 


sea  s(  11 1, 


area  is  exteiuhd, 


Th 


le  amount  of  organic  matter  is  also  tl 


increased  liahilitv  to  cont 


aminatim: 


ten  much  increased,  renderinn 
the  water  a  more  suitable  medium  for  the  growth  of  all  kinds  „i 
bacteria.  The  heated  soil,  too,  after  tl 
their  development;  but  the  fact 


le  summer  weather 


mav  favor 


particularly  by  v.  Pettenkoft 

durino-  the  autumn  months.     Unfortunatelv  no  data  1 


or  on  which  the  greatest  stress  is  laid 
r,  is  the  low  erinji-  of  tl 


(iollectcd  in  Haltimoi 


'e  on  which  t< 


t)oint. 


hei>!;lit  oft! 


Ao  systematic   observations   I 


)  Dase  an  opinion  on  this  important 


le  .uround-watf 


lave  ever  hcci 
th 


le  li-round-water  at  diilereiit  seasons. 


ave  ever   been  made  on   thi 


tion 


nor  IS  iinv  inloi 


th 


ivailable  as  to  the  nature  of  the  soil  in  tiie  ditlerent 


iiiii- 


e  citv 


It 


portions  of 


IS  to  be  hoped  thai   the  new  topographical  survev  wil 
prepare  maps,  such  as  those  iiuuh;  for  Jierlin  and  other  cities,  !■ 
lug  the  distribution  in  the  wards  of  clay,  gravel  and  sandv  soil: 
(r)  Conveyawe  thruiu/li  Food  N/lft/^'.— Mere  the  chief  d 


\\(<\\- 


contammation  of  milk,  which   has   1 


mger  is  tl 


source  of  the  disease  in 


)een   shown    to   have   been 


many  epidemic 


conveyed  in  the  water  with  which  tl 


tlic 
The  infection  is  iisnallv 


possibility  of  direct  infection 


tl 


le  |)ans  are  scoured,   but  the 
must  also  lie  borne  in  miiul.  as  when 


lose  engaged  in  milking  the  cows  have  also  to  do  with. 


ami 


landl 


the  care 


inti 


of   persons    sick    with    the    d 


isease 


inspection  of  neither  milk  nor  dairie,- 


ialtimoi 


'e   liiis 


th 


We  need  information  regarding  tl 


ei 


r  condition,  and  also  the  i)rop()rtionate 


le  number  of  citv  cow-sheds  and 


amount  of  milk  supplied 


to  the  cit 
dairies  tin 
had.     Ev( 

exposed  to 
ceptible   t( 
licst  kind, 
altering  th 
lilown  in  a 
contain  ge 
reach  the  ( 
disgusting 
Mianure  in  i 
whole  grou 
ing  the  i)ai 
and  horribl 
in  many  in 
readily  und( 
There  does 
Health   OfK 
members  of 
of  the  faniil 
lived  in  a  sm 
stable  in  the 
about  in  a  m 
place  a  few- 
condition   as 
localitv.     Th 


I65J 


r,,i>hohl  Fnrr  h,   Baltimore. 


165 

'i^^>tz^::zJ:::^7  --t- '• -  -^ '^- 

l>«'l-     Eve,   «I,,,,C      "■■'"'      '■'""■''''■''  '»  •'■"'■'■""■I-- 

'••■I'til'lc  t(.    infection     .m,l  V  """''  ^''^"  '""^t  sus- 

i-t  kind,  p..  ^    :^^^  -Itnre   „.,.<Ii„n.    of  tl.o  vcrv 

'>loun  in  all  .li-  ,tions  fn„  .     1  ,'      V       ,    '   ''"''   """^   ■^"'-I'i"^-- 
-"ta,n  ,c.rn.s  wl.i       c. v       i  ""?"'   ''''''''  '""^^  -"^  "'•^"' 

-acl.  tl.:  open  pan         W,         "•'  ^""-'->^^-'^-^  "^v  <lai,,,  nu,ht 

iii»iinr(.  ■„,  ,,l„«c  |,roxi,„i„-  ,l„.       ,'        '""''"''"  ■""•  ""I'  l«'»l»  of 

:-' i™'HNy ,n,.,v, „„. .,„„, ii;:;::  ;  ,»-.";;:'> '■^•i-; 

111   iimnv    nstances  fi;«t;ilr„...      /•  '"'t.S  the  onlv  foo, 

■■ ■•»•■. 'r  z '::;:!  :''T,;::i,r;, '''^  "'"■"■'™" 

Hoal.l,  Office  c.a,'Xe  .     |:;hv    T'"'""'  ',""™"""'  '•'  "'""''  ""■ 
"f  tl,o  fan,ilv  l,a,|  |„,,i,  i|    ',  ""  '"  "?'  "•"•''»■  '""  '"eiiilHr, 

«".i  i..us,„aii .»,.;. ,,.';::,; ;;:;  ""'',■""'•  ■'■'-  i>»pi« 

rtaM,.  i„  ,he  bade  var.l  ivi,,,.    i     ,  "i'''  "'"'  "  """"'  >■•"»- 

1.1.C0  a  fe-v  bi„c.,<,  ,„»,„„■,,„„., :;  ,„  ;'  '■„,:":,':;;""™".'"" 

'■on,l,t„„i  a«  clisKMsti,,}-!,-  ,|irn  as  i,   I,,      I  '        ,     "'"  '"  " 

'V|.lmi.l  KM-iii,  will  „,■!.  """■     -*'."  ''"S  1»™  »lio«„  ,|,„,  ,!„, 

-'™ ".  an  i"M.:'.l.!i:::,,::f ;,.;::;;  ■ii^ri:';;:'-?'?'  ;■' :'°-  -' 

excreta,  lif^hting  on  milk   meut  an,l  .,  '"^  "'  ^''<'  ^''"'^d 

^^''ie  for  tl.eir  .levolop,!;'„t  '"''  "^-^'^^^^•^'  ''^^  ->"^litio„.s  suit- 


Kj 


166 


Williiiin   Onle.r. 


[16fi 


Cold,  lili'IcsH  tliiiif^s,  figures  makd  no  iiioro  iiiipreHHiou  on  tlu!  ordi- 
nary mind  tliiin  would  tlic  cnmncration  of  the  davH  of  the  y<'!ir;   noi 
more  also  docH  the  Htutenicnt  that  at  an  estimate  of  an  averajrc  of  hn 
weeks'  illness  to  each  case,  there  have  been  from  18H8  to  1H92  (iiiclii- 
sivc)  ,S2,")1'J  weeks  of  lin^'erin<j  illness,  about  IGOO  years.     W  jien 
beneath  untouoiied  lintels  the  destroyer,  (rtjuo  /xnh;  enters  onr  own 
door,  in  weeks  of  suspense,  if  not  in  the  anguish  of  loss— needless 
loss— such  as  that  which  has  been  felt  in  ll-IG  families  of  (his  city 
within  five  years— then  only  can  be  realized  to  the  full  the  bitter 
penalties  attached  to  the  transfiression  of  well-known  sanitary  laws. 
The  direct  money  loss  in  the  community  from  typhoid  fever  alone 
durini;  the  past  five  years  may  be  readily  estimated.     The  loss  i„ 
waj-es,  the  expenditure  on  attendance  upon  the  sick,  and  the  cost  of 
feediuii-  may  be  placed  at  the  very  low  averajre  often  dollars  a  week, 
which  would  make  a  total  loss  of  825,120  dollars  for  the  five  yeursi 
above  160,000  dollars  a  year,  to  say  nothin<i  of  tlie  yearly  loss  of 
229  lives— lives,  too,  at  the  period  of  oreatest  value  to  the  State. 

\'on  Ziemssen  has  calculated  that  between  1881  and  1888,  owing 
to  the  extraordinary  reduction  already  reierred  to  in  the  prevalence 
of  typhoid  fever  in  Munich,  thcr<'  had  been  a  saving  to  the  inhabit- 
ants at  large  of  very  nearly  ;5,0()0,000  of  marks;  and  he  states  that  il' 
th(i  morbidity  had  persisted  during  these  eight  years  at  the  same 
rate,  the  loss  in  wages,  cost  of  feeding  and  attendance  would  have 
reached  a  total  far  in  excess  of  the  actual  .-ost  of  the  sanitary 
imj)rovements. 

In  conclusion  it  may  be  stated  that  the  following  are  the 


167] 

lias  no  He' 

the  large! 

major  poi 

medical  oi 

ening  and 

warrants  t 

;ige  the  d( 

present  rat 

The  water 

iilong  the 

the  danger 

•{.  To  in 

of  dairies  i 

I'c  clean  a: 

polluted  da 

4.  In  the 

>liould  be  a 

Nnte.—'ri 
tli(^  Vitdi  SI 
•I  S.  Billing, 
have  stated, 
included.  ( 
tinctures  the 
years  coveret 


Mkahkues  Xecessauv  r)h  the  FreveiVtion  of  the  Diseask. 

1.  Scrupulous  care  on  the  part  of  physicians  in  charge  of  cases, 
that  (./)  the  stools  are  thoroughly  disinfecto.'d,  and  (i>)  that  all  sources  of 
contamination  are  prevented  from  the  soiled  clothing,  etc.;  (c)  active 
co-operation  in  notifying  the  health  authorities  of  the  existence  of 
cases. 

2.  The  presence  of  ty|)h()id  fever  in  a  city  means  bad  drainage,  oi' 
|)olluted  water-supply,  or  both,  and  since  the  morbidity  and  nior- 
tality  may  be  reduced  to  a  minimum  by  a  i)roper  sewage  system  and 
an  ample  supply  of  pure  water,  it  behooves  civilized  communities  to 
insist  upon  these  elementary  Ineasures  of  public  health.     Baltimore 


167] 


Typhoi,!  Fcnr  /„   lialliniore. 


167 

;:;:;:r:r  ■;;;;;:!::;;;:■,  ;;":;;:■■';' -i.:-™...- 

'•"'!<"  i'""i...iofwi,i„i,Li,  1  ""■  ^•";:""  'i"»  .».iM,„,.,„,  ,i„. 

-"<»i  "11 r  „r  i„,,,  ,;,«;::':.  ;;,""■ '"-'  ';'i'""  -'■  "■« 

'"■"« '" i.ivci,  ,i„„.,.,.„ ,  ■•  " :  „  ■ ";."»7- ' - 

»B0  .1,,.  ,l,,„|,-,,,(e  fr  ,,      'l        f''"'""'-'''  "■"' '""I" Iruin- 

l.re..M,r.,,.„n      ,''"■'-;'    ™  -'■'■I   '«•  -I,,..,,  ,„„„  i,, 

Tl,«  .»UT  H„„-,.c,   ,„,,;'"'-'  '"  '"*™'  »■'«  "■'<!  l«... 

»i»..K .i„. «.r.:;  'J '  :,ri;  ;r' ;"■  ■;-"-« i"..-.... 

;./i::;:;:rS;;;;:::;;r::;-?;:r 

•f.  S.  Billings       ...J  ."  X        '^Vfolumlna   a,„l   /ia/ti,norr,  l.v  D,-. 

i"'l"de,l.     One  irLi.s     ...     H  "'''V- '''!""""''"''"'   '''''  ''''^'  ""^ 
v.ars  covoml  l,v  1  /'^^ ''**  ""'''"•'■^'  ^'"'•■'"K  the  six 

-tensivelvin  Balti  u2\tem         ^''f  .""'"'•''^  ^^'^  ■">'  l-vail 
^listriots,  and  th-it      ,    h    .i     '  ■'""  ''"'""^  ='"''  ''"  '■"'"f^'i" 


THI 


PHOrgss 


<^K  U  N/ll 


I  I 


THE  ARMY  SURGEON. 


BY 


WILLIAM    OSLER,  M.D. 

r«Or,SSOR    OK   V«,„C,NB.    ,o„NS    „«,.„.«,   „N,VKRS,TV.   „*tT.MOR,. 


i). 


i'l        I 


FROM 

THE    MKDICAL    NKWS, 

March  34,  1894. 


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surgeon 
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oflicer 


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wiiici 
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--rii 
they  may  i 

■llOSt     filVO 

■d'stiiibing  I 
"''  in   the 
Jisorder 

'■ilJudin, 


in 


If  to  1 


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-^ucli  as  hot 
■lielii-stdutj 
<-ine  as  the  h 
■ind  the  piii 
points  to  til, 
.';  alee  and  the 


Db  w  '"^  ARMY  ^i^^        X 

J°  treat  the  subject.     We  c",    LT  .""'"^  ^'»<='^  '>«  manage 

^^"^  of    the  more  salient  f^'.       ^  '°"°'''  ^^^ever.  apon  „ 

gating  that  about  Ms[lTZ  °'   ''^  ''"''^^^^      Mtel 

^y  too  particular  knowled  J         ,    ^  '*^°  '»  uuhamnor',,! 

'"edical  surroundings  it  ^^1.^,'^.''  '-^""ding  to  his  J  , 'v 
^"-«m.  index  cat^alog  e  *\7'",''?'--to  the  Hbr^^ 
t'onary,  and  the  median  it'-  /  '"^  ^^^ow  Jikg  .  ,  J' 
,<!^  to  describe  ^.1^°'^  °^  ^l^^  ^ate  war-h'  g  ' 
We  of  an  army  sSon  %T'''"'""'"^^  •''«^°^ded  b/th  ' 
the  wandering  "meSSai  Officer"'  "''  «°"^  "'ings  whS  ' 
J^'-equent  change  from  stattn  ,  T'  °^  '^^"^^e.  forego 
and    disadvantages;    but     f    .      '''^"'''^  '''^^ 'ts  hardshK 

un^oubtedIygooafoVthe;oJr'"'=^    of    .^sidence  t 

wide  mental  vision.     It  Jf    !'       '^  °°*  «'>  best  fo. 

-e  place  is  never  log  enotlT\  ^'^^^P^'  ^^  --c'e  t 

deeply  as  to  make  the  process  of  tr      'f  '^^  '•""^^  strike    o 

I      "bout  local   ties.   inde^Lnt    f"tf '^*^"°" '"<>  P^^'^f^' 

•I'-'oy  surgeon  escapes  many  o7  the   .nl.-^"'"°'  '^«  y°""^- 

•-i^il  P"ctitioner-tho  n  '*'*'  ^^'"^^  f«t  t!.e 

^-owleije    ,  fP"'"'^*^"^'^  comfort  ZyU  "T'^'T  '"'  '" 

'Growth  i„  thp  n.     ■  '^"'fi'  '"uch,  but  in  »    •  ■^''^'alue 

^.i.,*   1  "  acquis  t  on  fif  fo  »    .  '"  seeing  wispiv 

^ ''ted  With  .levelopmentMl  ''  "°'  ''^'^^'^^JilyZ/o 

■'if^.  Which  adl  ;  '^'r''""'  ^han  that  de.^'tS*  • "  '^^^ 
■^'"i'ersin  thei   inv     .      '^  ^°  '^^  studies  of  1  '°  "'" 


. ' 


T><E  A RrviV  SURGED^     ---^-^      . 

at  the  closingexerc  ses  of  fh„  A       Z^^^  ^^""^^^-^  ^  address 

ton.  on   ''Therr;yarSX'w^?"^ 
consideration  on  acconnf  nf  ?.  "'*  '^  "^^^  deserving  of 

Dr.  Osier  and  the  Sn"  s  and  n  ??^^:T"'''^  '^'^'^°'=«on  of 
to  treat  the  subject  We  can  Z  T'^""'''^  ^'  '"^"^g- 
few  of  the  moie  sailed  eatur^'JrS'  'T"'"'  "P°"  "* 
stating  that  about  all  subier^  m  ^'^'''■^''-     A^'«' 

which  are  more  fredy  han£  bv  o'  "^  '°'"'  '^''^^""''^ 
by  too  particular  knowledge  ^,S  alf  f  °  "  ""hamper.! 
medical  surroundings  at  VVashLf'"^  '°  ^''  ^™y 
niuseum,    index    caLogue      at     v^      ,7*°    "^'^     "^rary, 

tionary,andthemeSh'istlorth:^T  "'^  "  '"' 
on    to    describe    briefly  thpT      ?     ^^  '**®  war-he  goes 

life  of  an  army  sTrgL  TTfre  '"''  ''''''''^  ^^  t^- 
the  wandering 'medicToJiLr  l^J^^^^^-^i^^^ 
Frequent  change  from  statinn  f      !    '  ''°°''^e'    forego, 

and  disadvantWrbut  f  Jl'''''°"  ''as  its  hardships 
undoubtedly  good  fo'r  the  pocke  TtT^^  °^  ^""'^"'=«  ^•- 
wide  mental  vision.     It  is  fnrH  ^°*  ^''""^^  ^^st  foi- 

one  place  is  never  loJg  nSto';  nt'"''  "  ^^^^'<=«  - 
deeply  as  to  make  the  process  of  tr  '^^  '°°'«  «*"''«  «C' 

Without  local   ties.  indeSdent  of    /l    ""^  k^ '°°  P*''^^'^'- 
I  army  surgeon  escap;s  mafy  of  the  U-'kP"'"^'  '^^  y°""e 
civil  practitione^the  pan^      -  -xet.es  whichfretjh^ 
-eary  waiting,  the  „SSntv  7"^'  "°"''  "'«  ^^'^^  °f 
'^eaven  of  life  denied  to  so  man/  '''?',  "^  change-that 
correctivetosomeunpleasantfTbies    lf°     f-  f"""'^  ^  strong 
'sleJ.der  grounds  is  sometime   so  acl.!''^''""'' °"  '^"^ 
'-unities  that  it  is  compamb L  to  tt  T 1°""'"^' '""'  '=°'^- 
^'^  the  insane.      la  a  nomad  ml  n      "''°"'  °*  ^^^"'^e"^ 

to  the  entertainment  of  wh  hi  r- '"'""'"  '"'"'^'^y- 
'^Vont.  lend  their  ever  reaJv  nH  n  '°  ''''""'  ^«e  and 
tl^e  history  of  the  profe  !i„n  n  '  """  '°''''°'''^  Prevail.  In 
-ent  that  i-iatiorp  "^S^s  Sn'n^'T'^^  ^°^  ''-  ^'--^te 
of  army  service  faithfulness  in  led'''  p  "''  "'"'^'^  ^^'-^^^ 
■insensibly  widen  the  powersVnd  n.  ^  f  ""^"  """g«  ^i" 
f^oments  of  despondSnly  c 'mlrt  ''  'f'  '""^"'^^'  -"^^  in 
knowledge  that  some  of^he  be^X?.  "'"'  '^""^  ^ 

whose  clinical  field  was  1  mLnT  '^'  ''°'°«  f™"-  men 
of  experience  is  notTn  sSnl  n'  k  ?"  ""^^-  ^^e  ^^lue 
Growth  in  the  acquJuion  of^""  •  '"'  '"  ^^^'°^  ^'-ly. 
cmted  with  development  ML;!;V\r'  "^'=^^^''^"'^  ^sso- 
fis  a  crystal  by  simple  acS,f  T-?"'°"^'^  ^'^'  "dentally 
J^  or,.anic  and  enduring  is  't'l,  J  t  "'"  »^°'^^'^  ^''ieh 
Y  «h-ges  of  anothef  k  nd  a  "d  ^f"'"'  '^'"^  "^^'^^^ 
character.  Alluding  to  the  •;/!./  ,  ""^  unmistakable 
surgeon  works,   it  fs  said   f.  ^^'  '°  ^^''^^^  the  army, 

-^tended  rang;  of  vari  t^^.t^^,--"-  ^t'^bility,  a  less  ' 
^'fe,  Which  adds  a  value  t^'  th„  .  .  "^'^'^  ^'"'  '°  "vil 
officers  in  their  investigat  Lns  nLlt  '"'."'  ^"'^  ^^^^^^^ 
cine.  Army  surgeons  sr^r^,  byg'ene.  dietetics  and  medi- 
they  may  follow\he  ,  "  f  L^r^^'^  '^-^  in  theirTorl 
-ost   favourable   circum" uteftir    "  ^''"'''  """^^^  "'« 

<i>^turbi„g  than  those  whih;:kituh''°°'  '"^'"^  '-« 
°r  m  the  routine  of  a  gene  tlhn  v  ^' '°  ^^"nily  Practice 
d.3orders  may  be  tracke!^  rom  i  ceZn  ,  '''"^  '=""'-- 
alluding  to  the  pursuit  of  th^  ".''^P''°'^  "^  "''Jse.  Dr.  O.sl^r. 
«uch  as  botany,  zoology  geolo^v  ?1  ""T^^^  *°  medicine. 
t.e/irstduty  of  the  m?dca  officer  T  '''"°'°^y'  «<^'^'^  '"^a; 
ciiie  as  the  best  way  to  serve  th^f  "  "^^'^''tl'eless  to  medi- 
^nd  the  p„blic.      Setting   aide  T"'-  '^'  P^°f«««i°n 

Pomts  to  the  experiments  an^obf  "":"""'"•  ^°'"''''  ^e 
.';aiceandthephysiologytf  TiLTn;  T-l'"'  ''''  ^'^^^"c 
M.a,   surgeon    in    the   UnS  sLV'^  '"'^  ^'""'^°"'- 

1833,  as  an  illustration  of  what  ha^r!"™^-    P""'«''ed  in 

'\We  circumstances  by  one   !„  °"' *°'*'^  ""^■"'°"- 

^k^rts  of  h.p        .■     y.°°e   who  w,s  quick  to  •■  grasp  the 


PHOPR;So|)    o 


TH£  ARMY  SURGEON.^ 


I"    MEDICINB 


lOHNS    HcirKlN 


^f.D.. 


'■^    I'NlViUMlv 


I  Al.TlMOKK 


h^lf  of  the  profession,  to  o  fe  'n  m"'""  '""'  °"  ''«- 
I  eparfnent  hearty  co  .ratJ  t  o  s  '  '}'''''  '''^^''-^ 
of  he  arran,.ements  whic  h  '  "  "'V'"  ^'-'P'^tion 
gathennj;.      Wjt,,  ,anar  t^!l  J       '"'''^^   P^'^^ible   this 

'he  schools  at  large  canLthl  ''  '"'*"^'  '^'^^^-^'on 
l^Seons  with  the^  fu,  Tt  .iK  o;'"'"'  /°  ^''^P  -"v 
g''ince  at  the  curriculum  J^  '''^"''  ''^^i'^R.  A 
^harp  reh-ef  the  disabili  e  u  '°!"'''«'"<  '^rin,'  into 
n;-st  have  proceede'  t^  f;  T  /'^'^  P'-ious  dasse 
of  wh,ch   have  had  to  nVk  "'''    "^^    '"embers 

knowled.^e  traversed   n  tJe  lect,;     '""'.^-"'^    ^'^'"--ible 
cises  of  the  session      Mnt  ..  '  '""'^  'aboratorv  exer- 

"  -  -my  medical  sZj'^'^l  °^  •■'''  'he  advant!"es 
°f  the  younj,  officers  „ Th  ,h  i  '"  ''""''"  "'e  cont^c 
under  whose  directions  tey  ,/'"'"?'  "'^'^  '^e  men 
'"  comparison  with  their  nre''^ """'>"  ^^^e  to  work 
-'fedin.s  and  ideas  w  11 '  t'" ^ j^''^/  ^'^  what  differ-' 
he.r  duties  in  the  various  po't  ,  "  1  T  "'  *^"'«'-  "Po" 
ass>;.ned.    Instea.i  of  ha  v  no  '''^  "'^>'  '>ave  been 

^-'»  'he  J:xami„in.  Do  ^  "°  '°"^-P^'haps  to  one  fresh 
-;'hority  at  U  ashrn^torlr  ';T'"^°''"--°^^''^entrll 
retary  of  War.  and  of  an  exnnr  '"  ^"'hroned  as  Sec 
youn.  officer  who  ha  ^n  ,  ""  •'^"'"eon.r.enerxl  tt: 
|-offour..ont^'';;;^S  ;^;el,,htfu,opSu;:;! 
'ngs.  which  teem  with  ;em  nl  V"'P'^'"»  ^"'•'ound- 
corps  and  of  the  .reatn^     '/ p^r  f""- ^"'"^'^  °^  '^l 


officer,  I  _say,  must  be  iiuleetl  a  nuKldy-mettied  fellow 
who  does  not  cany  away,  not  alone  rich  stores  of  infor- 
mation, but,  most  precious  of  all  educational  {;ifts,atrue 
ideal  of  what  his  life-work  should  be. 

Miiiil'crs  of  tlh-  (.]i(u/ii(itiiii;  C/ass :  Though  to  you  it 
may  not,  to  me  it  seems  peculiarly  ap[)ropriate  that  the 
Surgeon-Cieneral  should  have  asked  a  civilian  to  make 
an  address  on  this  occasion.  With  the  strictly  military 
aspects  of  your  future  life  you  have  made  yourselves 
familiar ;  of  the  merits  and  demerits  of  the  army  as  a 
career  for  a  physician  you  have  in  the  past  four  months 
heard  very  much  ;  but  about  all  subjects  there  are  some 
questions  which  are  more  freely  handled  by  one  who  is 
unhampered  by  too  particular  knowledge,  and  this  is 
my  position,  I  may  say  my  advantage,  to-day.  For  me 
the  Army  Medical  Department,  so  far  as  particulars  are 
concerned,  means  a  library  with  unsurpassed  facilities, 
the  worth  of  which  is  doubled  by  the  liberality  of  its 
management;  a  museum  in  which  1  have  spent  some 
delightful  hours  ;  an  inde.x-catalogue,  which  is  at  my 
elbow  like  a  dictionary  ;  and  the  medical  history  of  the 
late  war,  particularly  the  volumes  by  Woodward  and 
Smart.  Further,  I  ha\  e  here  and  there  gleaned  in  my 
general  reading  in  the  history  of  the  profession  of  this 
country  facts  about  the  corps  and  its  members.  I  have 
read  the  spirited  vindication  of  John  Morgan,  who  may 
be  called  the  first  Surgeon-General,  and  I  am  familiar 
with  the  names  and- works  of  many  of  your  distinguished 
predecessors  who  have  left  their  mark  in  our  literature. 

Hut  as  I  write  an  aspiration  of  the  past  occurs,  bring- 
ing me,  it  seems,  closer  to  you  than  any  of  the  points 
just  mentioned,  a  recollection  of  the  days  when  the  de- 
sire of  my  life  was  to  enter  the  India  Medical  Service, 
a  dream  of  youth,  dim  now  nnd  almost  forgotten — a 
dream  of  "  \'ishnu  land,  what  i\vatar  !  " 

Speaking,  then,  from  the  vantage  ground  of  my  ignor- 
ance, let  me  tell  you  brietly  of  the  opportunities  of  the 
life  you  have  chosen.  First  among  your  privileges  1 
shall  place  a  feature  often  spoken  of  as  a  h'lrdship,  \iz., 
the  freepient  change  from  station  to  station.  Permanence 
of  residence,  good  undoubtedly  for  the  pocket,  is  not 
always  best  for  wide  mental  vision  in  the  physician. 
Vou  are  modern  representatives  of  a  professional  age 
long  past,  of  a  day  when  physicians  of  distinction  had 


no  settle.1  homes.  Vou  are  Cyprid  larva>.  unattached, 
"^^"''y'"^'"'"'^''  ^^e'"^'  '""ch  in  manv  places  ;  not  fixed 
as  we  barnacles  of  civil  life,  head  downward,  degenerate 
descendants  of  the  old  professional  Cirripeds.  who  laic! 
under  contribution  not  one,  but  a  score  of  cities 

Without  local  ties,  independent  of  the  public,  in,  while 
not  exactly  of,  our  ranks,  vou  will  escape  many  of  the 
anx.et.es  which  fret  the  young  physician-the  pangs  of 
d,spn.ed  worth,  the  years  of  weary  waiting,  t„e  uncer- 
tain y  of  the  effort  ;  and  perhaps  those  sorer  trials  inev 
itable  in  an   art  engaging  equally  heart  an<l   head   in 
which,  from  the  very  nature  of  the  occupation,  the  for- 
mer IS  apt-in  Imer  spirits-to  be  touched  with  a  .-riev- 
ous  sensibility.     In  change,  that  leaven  of  life  denied  to 
so  many   you  will  find  a  strong  corrective  to  some  of 
the  most  unpleasant  of  the  foibles  which  beset  us      Self- 
satisfaction,  a  frame  of  mind  widely  diffused,  is  manifest 
often  m  greatest  intensity  where  it  should  be  least  en- 
couraged, and  in  individuals  and  communities  is  some- 
imes  so  active  on  such  slender  grounds  that  the  condi- 
lon  IS  comparable  to  the  delusions  of  grandeur  in  the 
msane.     In  a  nomad  life  this  common  infirmitv,  to  the 
enterl.a,nment  of  which  the  twin  sisters.  Use  and  Wont 
end  their  ever-ready  aid,  will  scarcely  touch  vou,  and 
for  this   mercy  give  thanks;   and  while  you   must    as 
men,  entertain  many  idols  of  the  tribe,  vou  mav  at  kast 
escape  this  idol  of  the  cave,      l.-.njoying  the  privilege  o 
wide  acquaintance  with  men  of  verv  varied  capabilities 
and   training,   you    can,    as   spectators  of   the  r   manv 
crotchets  and  of  their  little  weaknesses,  avoid   placm' 
an  undue  estimate  on  your  own  individual  powers  and 
position      As  Sir  Thomas  Browne  says,  it  is  the  ■'  nim 
bier  and  conceited   heads  that  never  looked  a  de.^ree 
beyond  their  nests  that  tower  and  plume  themselves^  on 
l.ght  attainments,     but  "  heads  of  capacity  and  such  as 
are  no    full  with  a  handful  or  easy  measure  of  knowl- 
edge  think  they  know  nothing  till  thev  know  all  " 

P.ram/ya.inthus  attaining  a  bn  ader  mental  plat- 
form, you  may  miss  one  of  the  great  prizes  of  the  pro 
fess,on-a  position  in  a  community  reached  in  length  of 
days  by  one  or  two,  who,  having  added  to  learning  cul- 
tu.e   to  wisdom,  charity,  pass  the  evening  of  their  lives 

eif   oVa"  n  °'  "^^■■-°"-«"-  -d  of  their  kin       To 
g.ft  of  Apollo,  not  the  Surgeon- CJeneralship,  not  distin" 


■  .i 


guished  position  in  science,  no  piofessoisiii|),  however 
honored,  can  e(|iial  this,  this  which,  as  w.inderin^j  Army 
Surgeons,  you  must  forego.  Fortunate  is  it  for  you  th.it 
the  service  in  one  place  is  never  long  enough  to  let  the 
roots  strike  so  deeply  as  to  make  the  process  of  trans- 
plant.ition  too  jjainful.  .Myself  a  peripatetic,  I  know 
what  it  is  to  bear  the  scars  of  jiartings  from  comrades  and 
friends,  scars  which  sometimes  ache  as  the  memories 
recur  of  the  days  which  have  down  and  of  the  old  familiar 
faces  which  have  gone. 

Another  aspect  of  the  life  of  the  Army  Surgeon,  isola- 
tion in  some  degree  from   professional  colleagues,  will 
inlluence  you  in   different  ways— hurtfully  in  the  more 
dependent   natures,  helpfully   in  those  who  may  have 
learned   that   "not    from  without  us,  only  from  within 
comes,  or  can  ever  come,  upon  us  light  "—and  to  such 
the  early  years  of  separation  from  medical  societies  and 
gatherings  will  prove  a  useful   seed-time   for  habits  of 
study,   and  for  the  cultivation  of  the  self-reliance  that 
forms  so  important  an  element  in  the  outfit  of  the  physi- 
cian.    And,  after  all,  the  isolation  is  neither  so  enduring 
nor  so  corroding  as  might  have-  fallen  to  your  lot  in  the 
routine  of  country  pr.actice.     In  it  may  be  ret.iined,  too, 
some   measure   of   individuality,  lost   with   astonishing 
rapidity  in  the  city  mills  that  rub  our  angles  down  and 
soon  stamp  us  all  alike.     In  the  history  of  the  profession 
there  are  grounds  for  the  statement  that  isolation  pro- 
motes originality.     Some  of  the  most  brilliant  work  has 
been  done  by  men  in  e.xtremely  limited  spheres  of  action, 
and  during  the  past  hundred  years  it  is  surprising  how 
many  of  the  notable  achievement.s  have  been  made  by 
physicians  dwelling  far  from  educational  centres—  [enner 
worked  out  his  discovery  in  a  village  ;  McDowell," Long, 
and  Sims  were  country  doctors  ;    Koch  was  a  district 
physician. 

So  much  depends  upon  the  sort  of  start  that  a  man 
makes  in  his  profession  that  I  cannot  refrain  from  again 
congratulating  you  on  the  opportunities  enjoyed  during 
the  past  four  months,  which  have  not  only  added  enor^- 
mously  to  your  capabilities  for  work,  but  have  familiar- 
ized you  with  life  at  the  heart  of  the  organization  of 
which  hereafter  you  will  form  part,  and  doubtless  have 
given  you  fruitful  ideas  on  the  possibilities  of  your  indi- 
vidual development.     Naturally  each  one  of  you  will 


desire 

and  1( 

plan  f 

Thr 

that  o 

the  ro; 

thougl 

and  in 

hearts 

ness  is 

<■/('  wha 

couragt 

intelleci 

your  m 

other,  y 

powers  1 

ranks. 

a  wide  ( 

ness  in  y 

five  or  te 

that  com 

truth,  no 

many  of 

familiar  v 

nothing  si 

morning 

and  pictur 

were  new- 

and  if  the 

be  there. 

text-books 

stones  in  tl 

the  art.     1 

attitude  of 

Dan  to  lie 

desolation, 

'■aurence  Si 

know  not  tli 

within  them 

ot  the  mean 

'n  the  ear 

fully  as  grea; 

fulness  in  th( 

your  powers. 


P''}n  of  aaion.  '      "'^'  '  """k  -should  he  your 

thal'ordo-;;;^^'h'e"  Z' '""  ''!'''■  •••"  '^""'i"""   beyond 

'houi^ht  for,  the  niorro«  nvjn  .  '  '''"'"^■^^^  "''•  '■•'><in,' 
and  ,n  sonie  for,,,  or  o  he  . '?  ^'"'  '''^' ^''  ^""'e  time' 
hearts  ,hi,  ,„,,,„^  „^  t  e  k4e  oTrn  '."'^  "'^'"-  '^-^  « 

"'"  -bat  hes  clearly  at  a  1  • ''T'"^'  ''  ',  '"^'-«,  but  tL 
.'^""'■aj^ed  in  nulitary  ci  , ,  '  ,'' T'^^  ^'""''^  '^  "ot  en- 
'ntellectual  pro,.ess  to  '    , , '     "['  "^  >""  ""  -^^iapt  y^,", 

°"^er,  yo„  u,,i  ,,  j^^  1  ttle  bv  ,  r,'""'"''  "^  «°'>'e 
Po^vers  without  which  no  man  if  "'  "^°'*'^  ^^'''yins 
''-•nks.  Vour  opportunitL  7n  ",^  "'"'^'^  ^'''''"e  in  the 
•■^  -de  field  in  medic  .'  and  L?'-^'  "'"  ^^^^  '"^^  '•- 

-oth.ng  slip  by  j.„,  .  the  or  !"  '"■■'">■  -"-S'lns.     I  et 

■"-n.n,.  routine  maf  l"'  h"' '""''^"™  ^'--^^  of    S 
-d  Picuued,  but  stud'y    ad   ot'"  """'■'Y^'^'  ^'--"^^d 
were  new_so  it  is  so  f  „  w  1        ^^P'^-'ately  as  thouj,d,  it 
'^ncl  if  the  spirit  of  the    tuienr'' ■''"^'  experience  ^^^es 
be  there.     Look  at  i^  c^  's  It'V"  '''!  "^^  '^^^  -  ^ 
ext-books  and  n,onographs  Z  ^?"  "'  ^''"^"^f^^'"'  °f 
stones  ,n  the  progress  of    „,';.  ?     ■     ,  '°  "^'''"y  steppin.,. 
'"e  -t.     This  w^I  sa^eC    T'''''T'  "--'°P'nent  ,''n 
•;«''>'de  of  the  men  w^trCl   iT  "!f  ^''^'^^'^  "'ental 
^^^'n  to  Heersheba,  and  a    eve   ,  ^      °'  P'--'"^'"^e  f.o.n 
desolat,on,    ,ts    d,ea,ines      Z?]^  "' """  "P""  ''s 
Uuience  Sterne,  we  can  -,  v.  T  "'onotonv.     With 

'<now  not  that  the  ba,ren,'etr '"■'"'>■  ^"'  '^'  -"«  thev 
-th-n  themselves,   a  res  to"    "'rV''^>' ^°'"P'-n 

^--'y  -.^— ";;:'h;;c^s^-  ^•^^^■^"^^^-  -"  be 

f'-lness  m  the  day  of  sma     fh"'""^^  '"  <^'vil  life.     Faith- 
>-"•  powers,  cor;ect,::;';;:^E-;;^;-ns.blywid^ 

•  '^"•^'  'n  moments  of 


despondenry  comfort  may  be  derived  from  a  knowledge 
that  some  of  tlie  best  work  of  the  profession  lias  come  from 
men  wiiose  chnical  Held  was  limited  but  well-tilled.    The 
important  thing  is  to  make  the  lesson  of  each  case  tell 
on  your  education.     The  value  of  experience  is  not  in 
seeing  much,  hut  in  seeing  wisely.     I^xjierience  in  the 
true  sense  of  the  term  does  not  come  to  all  with  vears, 
or  with  incieasing  op|)Oitunities.     Crowth  in  the  ac(|ui- 
sition  of  facts  is  not  necessarily  associated  with  develop- 
ment.    .Many  grow  through  life  mentally  as  the  crystal, 
by  simple   accretion,   and  at  fifty  jiossess,  to  vary  the 
figure,  the    uni(  ellular  mental   blastoderm    with   which 
they  started.      The  growth  which  is  organic  and  endur- 
ing, is  tot.illy  diiferent,  marked    by  changes  of  an  un- 
mistakable character.     The  observations  are  made  with 
accuracy  and  care,  no  pains  are  spared,  nothing  is  thought 
a  trouble  in  the  investigation  of  a  problem.     The  facts 
are  looked  at  in  connection  with  similar  ones,  their  rel.i- 
tion   to  others  is   stuilied,  and    the   experience   of   the 
recorder   is   compareil    with    that    of  others    who  have 
worked  upon   the  question.     Insensibly,  year  by  year, 
a  man  finds  that  there  has  been  in  his  mental  proto- 
plasm not  only  growth  by  assimilation  but  an  actual  de- 
velopment, bringing  fuller  powers  of  observation,  addi- 
tion.U  capabilities  of  nutrition,  and  that  increaseil  breadth 
of  view  which  is  ol  tne  very  essence  of  wisdom. 

As  clinical  observers,  we  study  the  experiments  which 
Nature  makes  upon  our  fellow-creatures.  These  experi- 
meiits,  however,  in  striking  contrast  to  those  of  the 
labor.-itory,  lack  exactness,  ])ossessing  .is  they  do  a  vari- 
ability at  once  a  despair  and  a  delight — the  desp.iir  of  those 
who  look  for  nothing  but  fixed  laws  in  an  art  which  is 
still  deep  in  the  sloughs  of  Empiricism  ;  the  delight  of 
those  who  find  in  it  an  expression  of  a  universal  law 
transcending,  even  scorning,  the  petty  accuracy  of  test- 
tube  and  balance,  the  l.iw  thai  in  man  "  the  measure  of 
all  things,"  mutability,  variability,  mobility,  are  the  very 
marrow  of  his  being.  The  clunteh'  in  which  you  work 
has,  however,  more  stability,  a  less  extended  range  of 
variation  than  that  with  which  we  de.il  in  civil  life.  In 
a  botly  of  c.'irelully  selected  active  young  men,  you  have 
a  material  for  study  in  which  the  oscillations  are  less 
striking,  and  in  which  the  results  of  the  experiments,  /./•., 
the  diseases,  have  a  greater  uniformity  than  in  infmcy 


'•«  •■'«.;.  stand,,,-.!  of  .  o    ;,    ,  1"\°"'''«''  ">•"  tl.ey  serve 

"f  ^Inve  to  reach  the  low     "       ?        "  '   '"  '-'^'1  practi.-e 
P;''"^  "'  the  treat.,,;;    ',;;^.;'::-'^"i'y  of  ar.:,.  his! 

•"rf  ^yn,,non,at„lo.v  haJecoJ^f     ''    "'"^'  '°  ^''°'"^'y 

'I'-xea-se  under  the  most ^avo,.        "'""'•''  '""'"'V  ^^f  a 
('e-'n,ents  are  n,o,e  idea    U  '       '^  '■'■'""stances  ;  the  ex- 
Jan  those  whi.  h  prevail  eL""^?""-^  '-^^-^  '''-^''-''in" 
the  routine  of  the    J,  :    ,    '      '  '"■      "'">'  '"■■"^'"'^  ">■  m" 
"-"  disorders  c.,:^^^'^;^;    .^'-»-  of  the  ,:o„  " 
']'  '^^^"i  be  done  in  no  othe      ,       r         ""-'^P'i""  to  close 
'•-'-""-  for  the  Tnt tu:,^!t:dr;''"'^^•'•^■■^-''''e 
:'«'•e;.nec,ualled.     This,  whi  h ,?,  •        '"■'"'"  ='""^'^"""s 
'"  the  .ntrinsic  edncat  o  ,    f  \  ..tt"!"'  '?^  appreciated 
deeded  adv,ant,,;,re  ove,-  vo  r I  '''"'''■'•  ^''^'-^^  >0'>  a 

Vour  extrao-cimarv     a  r      .     ^""■"'  '^'■'^""•^'" 
•I'-JdaKeysto'lUfC'T"'""'^-- 
^aLfornu,,  affords  unequa   Id  f '"li,    "!-"'   '"    ■'"""'<^'-n 
•"•;»>•  of  the    vexe.l   p,o    e!,L  'n        ',    '■  "'"  ^""'>-  "^ 
indeed,  which  in  the    live  !i  '"^^"^'"e-facilities 

be  studied  a,e  ec,ualle       '     '^   "*  •'"°''^'^  conditions  to 
-  .be.e   ,nentio'„"f  L:  "fT""  'i"  '-■'^■''  "-•     ^  t 
P'oluahly  en,a,e  your  attention     v/"'j^^.'^    that   ,nav 
'"Portance  at  present  than    he  se«l    ''"'■^"°"  '^  °'  '"'^'^ 
the  vanetiesof  feverin  the   V  't  .nd'^""'''  ''''"''''•'  °' 
of  liaun,j;a,ten  in  St   I  ol    u  i     ?^"'"''-    '^"'''^  studies 
'"  the  Southern   Sf  es        '  "/  ^'"''^'''^-'^  ^^"''  "'hers 

^dduion  to  typho-i'  e.'er'Sr  .:'!  '"''''''''  '"-  '"         ' 
affecfons-there   are  other    ever       ""-"^'^    ™'"'"on 
and  morbid  anaton,y  of  u'  ichs,   1         ^>"^Ptomatolo,.y 
dation.     In  this  you  will  ^   , !n  '"  "''.''""■^  ^'areful  eluci- 
notable  p,-edeceiors  i    the    ^n, '""  ."  ""  '""''^''^'^^  '^^ 
"'"■•ks  of  \\•ood^vard  and  Sma^  ' , '  '".''^  '"  '^"^  '"'''haustive 
a'b.de,l,  and  which  are  aS,'  "  " f','^  '  "''^'^  ^^'"-'^"'y 
a  basis  f,on,  which  vou  ..a  v'    art."        '''  '  °"  ^^'"  ""^ 
-       ma>  start  your  peisonal  observa- 


lions.  More  particulaiiy  in  this  direction  do  we  need 
careful  an.itoniical  investiK.Uion,  since  the  symptomatol- 
ogy "f  leiiain  of  tlic  alledions  in  (|ucstioi.  has  much  in 
common  with  that  of  the  ordinary  continued  fevers  of 
the  North.  I  may  call  your  attention  to  the  satisfactory 
settlement  of  the  nature  of  moantain  fever  l)y  army 
sur^jeons,  and  neetl  hardly  add  that  the  specimens  con- 
tributed by  iloff  and  by  Oirard  to  this  museum  tlemon- 
strate  condusively  that  it  is  in  reality  typhoid  tever. 

In  the  Southern  posts  malaria  with  its  protean  mani- 
festations presents  still  many  interesting  problems  tor 
solution,  and  you  will  leave  this  school  better  equipped 
than  any  of  your  predecessors  for  the  study  and  differ- 
entiation of  its  less  known  varieties.  With  jmsitive 
knowledge  as  to  the  etiuloj^'y,  anil  a  practical  familiarity 
with  methods  ot  blood-examination,  you  can  do  much 
in  many  localities  to  vjive  to  malaria  a  more  definite 
position  than  it  at  prebciu  occupies  in  the  |)rofession, 
and  can  offer  in  doubtful  cases  the  positive  and  satis- 
factory test  of  the  microscope.  The  hematuria  of  the 
.Soutii  requires  to  be  studied  anew— the  lilarial  cases 
separ.Ued  from  the  inalari.il,  and,  most  important  of  all, 
the  relation  of  quinine  to  hematuria  positively  settled. 

In  the  more  distant  posts,  where,  so  far  as  the  soldier 
is  concerned,  your  opportunities  for  study  may  be  lim- 
ited, you  may  add  greatly  to  our  knowled^je  ot  the  dis- 
orders prevaUnt  among  the  Indians.  .More  particularly 
do  we  need  additional  information  as  to  the  frequency 
of  tuberculosis  among  them,  and  its  clinical  history. 
One  of  your  number,  Dr.  Edwards,  has  already  fur- 
nished ailmirable  statistics  upon  this  point,  hut  the  . '1.1 
is  still  open  and  much  wi  lains  to  be  done.  In  this 
connection,  too,  you  may  be  able  to  carry  saving  ivi'.,\i 
edge  upon  the  etiology  of  the  disease,  and  enforce  regu- 
lations for  its  prevention.  You  have  only  to  turn  to 
the  Inde.x-catalogue  'o  see  how  scanty  in  reality  are  the 
facts  in  the  nosology  o!  the  North  American  Indian. 

At  many  posts  there  will  be  presented  to  you  the  in- 
teresting eflects  of  altitude,  with  problems  of  the  greatest 
hvfu.k ','ical  importance.  An  excellent  piece  of  work 
icav  hi-,  done  upon  its  inlluence  upon  the  red  blood- 
••.i;;'-..i3cles,  in  •<(■  ;rmining  whether,  as  has  been  main- 
tiii:ied,  there  ib  .  .,  increase  numerically  per  cubic  miili- 
•aetre,  so  long  as  the  individual   remains  in  the  more 


rarefied  ..imos,,he,e.     |„ 


ch 


'"'"'»  remain  to 


■'  "leasiireinent 


'f  "/'»n  the  chest 


"e  sfitled  also 


's  still  |.„.|. 


'"'.'  "le  heart,  ami 


'■^'parity,  the 


h'A'h  altiliule: 


'">f  "11  'inestions  lel, 


'"  "ne  of 


■^  "l'"n  many  of  the  or.l 


■"'"),'  to  the  inll 


"iir  knoivledjre 


■e''se-milk-si,:k 


di. 

know 
ireased  si 


vo 


'".  perhaps,  anoth 


'"■"■>■  'liseases 


iiente  of 


ness 


er  |)er„lia,|y  ^me 


^rican 


'7'^e  of  its  etiology  hi     „!:'^'   "^  '^'"^ret.     Our 
«l  sinrf  tl,-  „....,   ^'    "''^   ""'   been   malerinlK.  :„ 


well  described 


"'■e  the  earl 


Th 


its 


V  papers  on  the  sub, 


ese  arc  but  .i  few  of  th 


symptomatoloj; 


:y. 


terially  in- 
lett,  which  so 


'es  to 


selv 

could  direct 
si-'tvicf,  trav 
and 


•">■   "lind.  to   which 


your  attention. 
e"'">;  with   seein 


le  <l'ieslion 
as  ch 


housp  of  cl 
any  one  of 


-^■%-w,-„,„;.,:rr,;':i:s'r 


in'i-ai  material 


list  think 
may  be  at  the 


^"^  suKKCstin-  theni- 

ance  affords,  .\ou 

years' 

ears. 


'»  a  ten  or  fifteen 


"hat 


ii  store- 


uny  one  (it    t'f^,,  /    "^    ^11    I 


its  a 
and 
of  the 
referied 


'"li'isition.  rendering 


indnite  value  t 


liable 


••omniand  of 


"1  itself  to 


,'ivi 


"K  you,  year  b 


yoti  painstakiuf,^  and 


o  you  |)ersonally  in 


y  vear 


accurate, 


fort 'to   which   i   ha;.e  1 'r:i?r"^  ^^''^'•i^"^ 


e  already  more  th 


an  once 


>-n;:irn;;:;::j:i;:„jjf-;;^';aved.eitchienyon 

Vour  activities  mi^^ht  be  en;,'      ,"';'-'  '7^"°"  '"  ^^^ich 
'•lymK  the  foundation  of  -.n     ?  "''"'^  >°"  =ire  thus 

'°  the  technical  si.t  of M;  "IT"""  '"  •^"  '""'^  -'"^t 
^^""^^  which  call  for  a  wo  d  ^^       °",'  '^"'^  "«  ""'er 
""  to  which  you  ma;  "e  sen^l  ""•     '"  '^'  ^°'"">t.ni. 
anny  officers,  you  ow'e  a  le^"      r.^  ''"f  '"•^'' "'°"^'' 
fession,  to  the  memhei-  of  wwl        •'"  *^""oral,le  pro- 
°  a  most  bindin,,  <:har.,cter        n  sit^;"'  ""'^'"'  *'>•  '^^^ 
advanta.^es  of  a  more  criticli  trnin  1       '""'  '"  ''^'''^'  the 
of  superiority  over  your    'J^' ''■^'"'"^^«'ve  you  a  measure 
be  apparent  in  you    de„  eTnor'h  .'"  ""'  "'^-  '^t  it  not 

favors.     There  are  re.Mon  ^      .     '^''^'^^'  ""t  to  .rrant 
;vhich  you  will  Ko  H  mi  si.'"  ^"""'"'  '•''^"''•/'■-V  to 
'°>;"'>'  to  truth  tn  the  s    :nce  "d  "\T^'""  "^^  «-Pe'  of 
f"d  your  lives  of  devo,  on  ^      '^  '"'''«  art  of  medicine 
Jatin^^  example.     Vol.ZZ'rT  '°  "'•-*">■  ^  ^timu 


lO 


everywhere  showing  that  you  are  at  all  times  faithful 
students,  as  willing;  to  teach  as  to  be  taught.  Shun  as 
most  pernicious  that  frame  of  mind,  too  often,  I  fear, 
seen  in  physicians,  which  assumes  an  air  of  superiority, 
and  limits  as  worthy  of  your  communion  only  those  with 
satisfactory  collegiate  or  sartorial  credentials.  The 
passports  to  your  fellowship  should  be  honesty  of  pur- 
pose and  a  devotion  to  the  highest  interests  of  our  pro- 
fession, and  these  you  will  tind  widely  diffused,  some- 
tmies  apparent  only  when  you  get  beneath  the  crust  of  a 
rough  e.Nterior. 

If  I  have  laid  stress  upon  the  more  strictly  professional 
aspects  of  your  career  it  has  been  with   a  |)urpose.     I 
believe  the  arrangements   in  the  department  are  such 
that,    with    habits   of  ordinary   diligence,   each  one   of 
you    may   attain    not  only   a    high    grade   of  personal 
development,  but  may  become  an  important  contributor 
m  the  advancement  of  our  art.     I  have  said  nothing  of 
the  pursuit  of  the  sciences  cognate  to  medicine,  of  botuiy, 
/oology,  geology,  ethnology,  and  archeology.     In  every 
one  of  these,  so  fascinating  in  themselves,  it  is  true  that 
army  medical  officers  have  risen   to  distinction,  but  I 
claim  that  your  first  duty  is  to  medicine,  which  should 
have  your  best  services  and  your  loyal  devotion.     \ot, 
too,  in   the  jjerfunctory  discharge  of  the  dailv  routine,' 
but  in  zealous  endeavor  to  keep  pace  with,  and  to  aid  in ' 
the  progress  of  knoivledge.      In  this  way  you  will  best 
serve  the  department,  the  profession,  and  the  |)ublic. 

Generalities,  of  the  kind  in  which  [  have  been  indult;. 
ing,  though  appropriate  to  the  occasion,  are  close  kin.'^l 
fear,  to  the  fancies  fond,  that  vanish  like  the  gay  motes 
which  lloat  for  a  moment  in  the  sunbeams  of  our  mind. 
Hut  I  would  fain  leave  with  you,  in  closing,  something  of 
a  more  enduring  kind— a  picture  that  for  me  has  always 
had  a  singular  attraction,  the  picture  of  a  man  who, 
amid  circumstances  the  most  unfavorable,  saw  his 
opportunity  and  was  ([uick  to  "  grasp  the  skirts  of  happv 
chance."  Far  away  in  the  northern  wilds,  where  the 
waters  of  Lake  Michigan  and  Lake  Huron  unite,  stands 
the  fort  of  Michilimackinac,  rich  in  the  nu-moiies  of 
Indian  and  Tvy,?;--,//;-,  one  of  the  four  important  posts  in 
the  upper  lakes  in  the  days  when  the  Rose  and  the 
I-leur-de-lys strove  for  the  mastery  o(  the  Western  world. 
Here  was  the  scene  of  Marquette's  mission,  and  here 


Siirjjeon 


II 

beneath  the  chanel  of  S.    r 

;-t.     Here  the  i^n  ^d' j ',« ".'^^  '  ->'  '-d  I>is  bones  to 
the  resolute  Du  L^h    had  h4id  '*■"'"  ''"°"'>'  '-^"rf 

'"gs,  Its  palisades  and  t,  r  '"  /'''"■  "•''^'  "''"'der- 
whoopsofOjibwas'n d(L  "V^'"^  *='^'>°«'  'he  war- 

-Kl  had  beei  U^  c'  ne  o  bS  "'  """"^  '^"''  '-I"-. 
fo"Kl.t  n.dus.  At  the  conl>  •'  "^'-'^^''^'^'•'^^  ^^"cl  of  hard- 
'iftertwo^enturiesof.f      ^      '°"  °^  '^^  ''^'^  ''^  '8n 

most  famous  of  her  minor  Jin,^  celebrated  one  of  the 
the  high-soundin,  Z^^o  ^uw\"''\'''''''''  '^^'^^^ 
-Kle,  and  into  cildefwhere  ,'"-'^"""'-»'^'<'"-c   far  and 

-■Salle  were  unknown  "efhl'Ts:'  ''"  '-"'^'' ■'^-' 
to  duty  at  the  fort,  which  hnlh'  '  "•''  ^^^'^^^^^ 

keep  the  Indians   n  c     ck   Sur  f"  u^lV'""^''  '"  "^^  '° 
then  a  young  man  in  the  ,^^^'""  "<^^'">""nt, 
i""e,  ,S2.,  the  accidenfl  'r'",'"  ""^  ''^"-     ^^"  the  .2d  o 
■St.  -Martm   a  I;!'   .?;"'''  ^^''l^'l^'-^''^  "^  -  "n-sket  „,ade 

stomach,  and   he     o  0'  eVed    '  i  ^  ""^'"' '''''^  "P^'  '^^^ 
fistula  of  an  exceptionall  ,?  f^^''"^"ent  gastric 

was  not  slow  to  e'  "thf  extZ'd  '"'^  '"'•  ^^<=— "' 
were  before  him.  Farlvln  7.  "''^P"''''^"'''^«  that 
'century  the  process  of      si.    '''°"''  '^^""''^^  "^  the 

'7  d-etodiJect  m:^sj;:;s;s7'^^.  '';!'^^'^^ '° 

"fa  v.tal  principle,  and  tlCh  Jl  i  ,  "  r '^' "'^''°" 
J.nce  had  long  been  entertained   th  ?  °^  '^  '"'^'^"t 

■""'^  ./W/.v.  The  serie  of  !  ■■  ''''°''  '^"^^tion  was 
on  St.  Martin  se  tied  fore  er  the"  "'"^'  '>'  ^'^^^'^-t 
<hml  capable  of  actlLon  f     -,       existence  of  a  sohent 

"- ^»"'  and  in^dSreSh:r:m^kr'f  r  "'''^'" 
processes  of  digestion  by  new  o  Isl     •  '^"°"'*^'^««of  the 

'"ents  of  the  stomach  ^he  tern,  .  "'  °"  '^^  »'°^e- 
the  body,  an.l  the  iLe^r^T  °^  "^"  '"t^nor  of 
f"°'l-  'be  resul,;  o f  h  t'  '  °'  "^^  ^'-^"-'^  -'ides  .f 
n.  an  octavo  volume  of  less  t^,^  "''"  ''^''^''^'''^''  ''^  '«33. 
•h'ough  it  one  cannot  b.!'?  ^'°  '"^'"•'  '"  '°°'<''i 
°f  a  very  large  J.art  o  ,  ,e  '"'"  ''"'  *'  '^  "^^  ^""''ce 
digestion;  but  ap.an a Itc^^t    '  f  "'"k'  ''"'^"^^"'^  '"'bout 

t^are,.i.4aboX:o?^:-.^;;-^c.i 
-"^->  in  ...e  rni,.,^,,„rAr,;:^.  ^!S;,^':^;;^:""''    ''•"■• 


[2 

of  its  kirnl,  aiul  on  every  paj^e  is  revealed  the  character 
of  the  man.     Ironi  the  first  experiment,  dated  AuL'ust 
I,  I.S25,  to  the  last,  dated  November  i,  1833,  the  obser- 
vations are  made  with  accuracy  and  care,  and  noted  in 
plain,  terse    ian-ua-e.     A  remarkable   feature  was  the 
|)ersistence  with  which  forci-ht  years  ISeaiimont  pursued 
the  subject,  except  during  two  intervals  when  St.  Martin 
escaped  to  his  relatives  in   l/)wer  Canada.     ( )n  one  oc- 
casion I'-eaumontbron-ht  him  a  distance  of  two  thousand 
miles  to  Fort  Crawford,  on  the  upper  .Mississippi,  where, 
in    rS2(>,   the   second   series  of  cxpeiiments  was  made. 
The  third  series  was  conducted  in  Washinj^ton,  in  i.S:;^' 
and  the  fourth  at  i'lattsburjr,  in    1833,     The  determina- 
tion to  sift   the  .[uestion   thorouj,ddy,  to  keep  at  it  per- 
sistentlv  until  the  truth   was  reached,  is  shown  in  every 
one  ot  the  238  experiments  which  he  has  recorded. 

The  opportunity  i)resented  itself,  the  observer  liatl  the 
necessary  mentil  eipiipment  and  the  needed  store  of 
endurance  to  carry  to  a  successful  termination  a  Ion" 
and  laborious  research,  William  iSeaumont  is  indeed 
a  bright  example  in  the  annals  of  the  .Army  .Medical 
Department,  and  there  is  no  n.ime  on  its  roll  more 
deservinj;  to  live  in  the  memory  of  the  profession  of  this 
countrv. 

And  in  closinj,^  let  me  express  the  wish  that  each  one 
of  you,  in  all  your  works  be.Ljun,  continued,  and  ended, 
may  be  able  to  say  with  him  :  "  '['ruth,  like  beautv! 
'  when  unadorned  is  adorned  the  most,'  and  in  prosecut- 
ing; experiments  and  incpiiries  I  believe  I  have  been 
guided  by  its  light, " 


LE 


AN  ADDRESS 
AND 


WIL 

Pr 


^-->c  uvin 


THE 


LEAVEN  OF  SCIENCE 


AN  ADDRESS   DEUVERED.TTHKOPHN.NG 


AND  BIOLOGY  OP  THE  UNIVERSITY 


OF  THE  WISTAR   INSTITUTE 


OF  PENNSYLVANIA,  MAY  =,,  , 


OF  ANATOMY 

894. 


BY 


WILLIAM   OSLER,  MD     FRro     r 

'"'   '*'i-u.,   F.R.C.P.    (LoND.), 

-       P-^essor  0.  Me.c,ne  i.  ..  .oHns  HopKins  University. 


Reprinted  from 

University  Medical  Magazine, 

June,  i8q4. 


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LEAVI 


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•i'\H 


AM)  l!|()|.i),,v  I 


WILLIAM   ( 


Prof 


fssdr  (if 


Um 


THE 


I-EAVEN  OF  SCIENCE. 


'""'^:^'""^"-"^'nn  <,„,„,,,,,, 


""    WIM\K.    INS  I,  I, 


'^ "'-■■-'->,;;.;„:;;::,:::;:::;::-"'- 


i:v 


l^t'PriiucJ  lr.,m 

l"mersitv  MeJic-il  M.i.u,,/,,,,. 

■'"lie.      iSgj 


Mr.    Pi, 

ieiiienibratic( 

iioMest   insp: 

own   sake,   s 

because  in  tl; 

a  deinocrac}' 

Roman  Iiisloi 

of  the  scrupu 

Ambarvalia, 

ihoiigli  feebli 

lives  of  their  < 

whicli  the  col 

the  touch  di 

equivalent  to 

:iii  ever-presen 

religion  of  Xi.i 

tiiose  who  wc 

importance  of 

ire  of  everythi 

Its  possibilities 

this  institution 

oblivion  falls  d 

perhaps  a  natne 

lorgotten  seem.' 

we  reco^niize  th 

teachers  is  passt 

"len  ;  and  in  tin 

^vise, '  as  they  ca 

tiiey  play  no  p 

invoked  nor  bles 

the  need  is  ever 

liays  of  trial  and 

colonial  colleges. 

To-day,  thrc 

lilting  monument 


'nil;  i.i:.\\|.:,\  of scii.;\ci.:. 


Mr.  Provost,  r.Ai.ij.s  \x,,  p, ...,,, 
reincnibrance  (,f  a  L-lorioiis 'tv,«f  •  '  '  '•'•^"•■'•' ^  '"  Hie  continual 
..oldest  inspiration,  a,:Mr;X;h;-"'^  ""'  "^'^'""^  '^■"'  ^"-r 
own  sake,  so  important  in  its  a  o'i  H  ^''''' •'""' '''  ''^^''^^'^'  ''<"■  its 
'-cause  in  the  strong  donu-n.ce  TfT^  ''■'''^^^^^-''  i«  it  not 
.'  ^■->ocracy,  we  hate  lo  t  V  J  '!;""7."-''  ^^  characteristic  of 
Roman  history  of  the  ceren.n  ^"ntnunty  ?     As  we  read   in 

of  ti.e  scrupulous  ^i^tm! :  :rrrr"f  ^  -^  "-^  "^^-^-•'  -^^ 

Ambarvalin,  the  dead  were  invoked  V,      "^"'"'''" ''^•^^■^•''''•'^ '''«  tbe 
tl>o"8h  feebly,  the  part  ud  ic     thi!  ''-'■-"'•ered,  we  appreciate, 

lives  of  their  successors,-  .."r'^^  "^  -"^'"-ty  played  in  the 
-i"ch  the  cold  rotUine  of  t^e  p  ^s^  t!"^"'^""^^  ■"'^-"-.  through 
■the  touch  divine  of  „ohIe  natu^s  ^  "t  '  """  "'  "'"^^'  '^°"' 
equivalent  to  this  feeling  exists   and  the  °"''  '"°'''"'  ''^'^-^  "" 

an  ever-present  immortalitv,  recognized  soT  ,  ""^  P""^'"""  '""^'^^  °f 
religio.:  of  Nunua.  has  lost  all  vafue  o  u.  w  " '  ""  •''  ''°^^'-^-  '"  ^'- 
those  who  would  recall  the  n.st  nn.i  ,  ^^  ^ ''''^^  e^^'"  impatient  of 
importance  of  its  recognition  .^'a'fa  .-l  :„":;''   '"■^'•^V"P-   ^he 

are  of  everything  save  the  present  witl    i      n  '  ""^'''""^  ^'  ^^ 

ns  possibilities.     Year  by  vear  tU  P''°«P^cts,  the  future  with 

t'=is  institution  fades  fron^  otU  the  c  nTe'7n°'  ,'''   '""'  ^'^-^  '"«^'^ 
■'''-■••""  falls  deeper  and  dee     r  oL     ii     /  ''  '"'  ^''^  ^"'^  "^ 

perhaps  a  name  alone,  remains  to  ,,u  ,     I""'  ""'''  ^  P«^^^«'^-  «>- 

-gotten  seems  i.ievi  able  "at  no  •  1''  '"'^  ^^'^'^  ^^'^"  ^"'^k.  To  be 
-  -'.."i.e  the  fact  that  th  da  -  ,  ^  ^l"  7"  °'  '""'^"^''°^>'  ^« 
teachers  is  passed  heedless  of  the  f  „  e  °  ^  ''  '^"''^^"^^  ^^"^ents  and 
^"en  :  and  in  the  second  state  subli',,  1\  ''"       ^''^  ''^""^'"  "^  these 

--. '  as  they  cast  their  e  be  W  to  0^'^'  "'""'  ''''  '  ^''-^'^  "^  ^^- 
"•ey  play  ,.o  part,  on  g;th  eil  '  look  down  on  festivals  in  which 
■■"voked  nor  blessed,  Btft  o  r  ^  l"  "'"'  ^^"'"^  "-"-  -^  neither 
"-.eed  is  ever  present  to  c  j    s     r'''" '"  "■'^' ''"^""'^  ■'"  ^'"'"-'^^ 


W  istar.      The  tribute  of  deeds  lias  already  been  paid,  to  him  in  Mr. 
splendid  structure,  to  all  in   the  stately  group  „f  academic  bnihli  . '. 
which  you  now  see  adorning  the  campus -the  tribute  of  words  rem  i--s 
to  he  able  to  olTcr  which  I  regard  a  very  special  honor. 

Ihil  as  this  is  an  Institute  of  Anatomy,  our  tribute  to  day  m-u  1, 
justly  restricted,  in  its  .Ictails  at  least,  to  a  eulogy  upon  the  men  nb 
have  taught  the  subject  in  this  r.iiversity.     About  the  professors],,,, '■ 
anatomy  cluster  memories  which  give  to  it  precedence  of  all  others    vr 
HI  the  septemviri  of  the  old  school  the  chairs  were  arranged,  with  i'".' 
of  anatomy  in   the  centre,  with   those  of  physiology,  chemist,  v    a,,','^' 
materia  medica    on   the    left,    while    those   of   practice,   surgery    ,,„■' 
obstetrics  were  placed  on   the  right.     With   the  revival   of  iJiini,,,,' 
anatomy  brought  life  and  liberty  to  the  healing  art,  and  thn.uohoH 
the  sixteenth,  .seventeenth,  and  eighteenth  centuries  the  great  nan.es 
of  the  profession,  with  but  one  or  two  exceptions,  are  those  of  the  ccv 
anatomists.    The  University  of  Pen ii.sy Ivan ia  has  had  an  extraonlnn,'; 
experience  in  the  occupancy  of  this  important  chair.     In  the  anti'.t.' 
and  a  quarter  wliich  en.Ied  with  the  death  of  I.eidy,  six  names  a„nc,r 
on  the  faculty  roll  as  professors  of  this  l,ranch.    Dorsey,  howeu  r  o„iv 
delivered  the  introductory  lecture  to  the  course,   and  was  sei/»l  th 
same  evening  with  his  fatal  illness  ;  an.l  in  the  next  year  Phvsi,  k  wi. 
transferred  from  the  chair  of  surgery,  with  Horner  as  his  adjuiu  t     ir 
reality,  therefore,  only   four  men  have  taught  anatomy  in  tins  nhoo! 
since  Its  foundation.    Physick's  name  must  ever  be  associate.l  w,ih  th- 
chair  of  surgery      We  do  not  know  the  faculty  exigencies  winch  Id 
.o  the  transfer,   but  we  can  readily  .surmise  that   the  youthfuha-.s  w 
Horner,  who  was  only  twenty-six,  and  the  opportunity  of  filchinLM^ 
surgery  .so  strong  a  man  as  Gibson  from  the  r'aculty  of  the  Universii,* 
of  Maryland,  then  a  stout   rival,  must   have   been   among  the  ,m:i 
weighty  consid^'rations. 

If  in  the  average  length  of  the  period  of  each  incumlu  ncv  th. 

chair  of  anatomy  in  the  University  is  remarkable,  much  more  so  is  it 

for  the  quality  of  the  men  who  followed   each  other  at   such  loii.^ 

intervals.     It  is  easy  to  praise  the  Athenians  among  the  Athenin.is  hm 

wher  IS  the  school  in  this  country  which  can  show  such  a  siuressici 

of   names  111   this  branch:    Shippen,   the    f.rst  teacher  of  anatomv 

\\istar,   the  author  of  the   fir.st   text-book   of  anatomy  ;   Horner  tk 

hrst  contributor  to  human  anatomy  in  this  country  ;  and  Iei.lv   .me.i 

the  greatest  comparative  anatomists  of  his  gencratior  ^     ( )f  iM.nmean 

schools,  Kdinburgh  alone  presents  a   parallel   picture,  as  ,h.,i„.r  ,1,, 

same  period  only  four  men  have  held  the  chair.     The  lonsrvity  and 

tenacity  of  the  three  Monros  have  become  proverbial  ;  in  Mirccssion 

they  held  the  chair  of  anatomy   for   126   years.     .Shorllv   before  the 


I'oiiiulatioii  of  this  sclio.il  \t 

t-..ht  uninterruptecliv  .'    r/:::f  ^!"'  ^"^^^^^'^^  '^  '^'^'-r.  and 
tlK' d.air  fornearly  the  same  I'uliinf  r  '°"'  ^^""''^  ^'■'^'^'^'   ^"-^''1 

I.e.iocl   has  hee„   covered  I,^•  the  ol  "^'  '"''  '''^'  '■^"'ai.ider  of  the 

--essor,  Sir  X^'inia,,,  T  u    e     the  n''"?'  °'  •^"'"  '  '^"^■^--  -><'   '-^ 
To  one  feature  in  t,,     ,    ', '"  P'^'-'''''^  '"'^"'"I'ent. 

afer  in  ])assing.     shipnen  J!.  "^  ^"'^'^^"'>'  '"   t'-is  school   I  must 

•'Hohn  Hun^..  ir:::^:^:;:' Cu^' ''"^' ^"'•' ^''"-■''">^' 

I'^can.e  in  addition  his  house- s.um-on  Ti  r  '""'  '-^^'^''-^''tagcs,  hut 
iKul  enjoyed  the  intin.ate  con  n,w  V  r''^'" '  ^^"'^I^'^^'-  ^^^t'' 
observer  of  nature  since  Aris2"'"""  "  ''"  "'"^^  -"-^''"^■e 
tillc  conceptions  and  syn.pathies  U  'i  /'IT  ''"''',  ^'!'^'*^''  '^'"^  "■"■'^  ■'^<^'"en- 
■nemher  of  o,„-  profess  on  and  v  o  '  f  T"  "'"  '"""  ""■'-'  ■'"  «- 
are  uniy  now  becoming  pr;v  din  ?  '^"•"'";"^'>ta]  notions  of  disease 
uas  derived  the  powerful  inspiratio,, V'l"  V'""''^  ^'"'"^  ^'''*'"  t'"'^ -"source 
One  of  them,  o„  his  retu^;;:  '  ;^^;;:r:t '"^^  ^■;ese  young  men. 
anatomical  classes  which  were  held  i,'  m  ,  •""''  ''"«""  '^"^  ''"'•'^t 
upon  that  career  so  notable  and  so  h       ^'\V^'*'<'"'^-'^  •  the  other  entered 

0'- the  Rather  of  American  W^^^^ 

from  Join.  Hunter  can.e  the  i.Lnce  w  HdMnT,'"'  '"  ''""  '''''  ''''''' 
"'-^^•1>-'.  -"<1  that  .eal  in  the  aau    it    ,)   '""■•'""' ^ 
...atclyled  to  the  splendid  collectio  s  of         WM^'Tr'"""''^  "'"■^"   "'^'- 
W.u.iAM  Siu,.,.K.v  shares  withT  ,     a         '•'*''»''■  ^^"'""^^  -Mi'seum. 

i"LM>.edical  instruction  in  this  ciuu^''^'^ 

iiad  discussed  plans,  but  it  was  mI  T  '^'  '"  ^''"^'''''^^  they 

0'  the  trustees,  and  who  roache  f  d"  7.  'T'  ''  ''''''  '''-'  ^■^  -- 
■Discourse,-  delivered  in  Z  -6-  ll  '  ''''"'"  '"  ''''  ^'^'^^''"^ed 
the  year  that  Shippen  signifij^  [o  Ih^  bo  .rhis"!,;'""  '''  "•^"'""  "^ 
professorship  of  anatomy  and  surgery  To  ,  '''"'"^"^^^•^  '«  '''^-'-'^Pt  a 
mentioned,  the  friendship  of  John  Hnnf  T,     ""J"^""'-  ^'^  ^   have 

1..S  celebrated  brother,  U'illhm     \  '  '  T^  '''  ■'^^"^^■^'^'  ''^'-'^^  ^'ith 

-s  Wniiam  Hewso,,  who  uhst'^M  "''''  ''"' "'^  fellow-pupil 
a-tonnstandphysiologi  t  a.""  n^^^  "^"'^"^  '^^  ^^"""-  -^  an 
n.e  blood,  and  whose  descend  Irhc  ""'"  "''  ^'^^  '^'"^^^'^^'^  "f" 
'ession  of  this  city.     No  wonder   H,  •'"  ^"°'"''"-^"^  ^"  th^' pro- 

.-"ger  Shippen'  on  h^  tun  i:';:''  '^'V'  "'"^'^^'""-  "-^'^- 
^l;onMluuxM.egunacour.seofle  tues;^  an";  "  ^r"^3-->^th  year, 
winch  was  delivered  in  the  State  H.^  ^     "'"'  '^'"  '"^'•"^^"ctory  to 

;^^-Ks  the  great  merit  of  ' "^L":  ^°^:^""'-  '^''>'-  'l'^>  1-" 
brought  from   the  Hunters  methl  ,      ''^'^^'"'ung,  and  of  having 

^^™>'  ■"  this  school.    ^vZTtt  7  ■  "'''""^  "■"•'^''  '-'^^  i^^w 

"■^^^i"  as  a  lecturer  and  1       dl  ^^f^;""  "^^^ -™  ^^i^nUe  to 

-"--^  i^e  taught  the  sui,ect  ^:^^rr:n^^''f;::: 


from  his  comaclion  with  this  institution  he  served  as  DirectorCen.  r,! 
of  the  Military  Hospitals  from  1777  to  17S1,  and  was  the  second  pi.s,. 
dent  of  the  College  of  Physicians. 

In   the  history  of  the  profession  of  this  country  Casi'AK  Wisi  \i 
holds  an  unique  position.     He  is  its  Avicenna,  its  Mend,  its  Kothci^iH 
the  very  eml)odimeiit  of  the  physician  who,  to  paraphrase  the  words  oi 
Armstrong,  used   l)y  W'istar   in    liis   J'dinburgh    (^.raduation    TliL-.sJs 
"Sought  the  cheerful  haunts  of  men,  and  mingled  with  the  hustlii,, 
crowd."     He  taught  anatomy  in  tliis  school  as  adjunct  and  proksso'r 
for  t\/entysix  years.     I'rom  the  records  of  his  contemporaries  we  Iian; 
that  he  was  a  brilliant  teacher,  "the  idol  of  his  class,"  as  one  ol  his 
eulogi.sts  says.     As  an  anatomist  he  will  be  remembered  as  the  author 
of  the  first  American  Text- Book  on  Anatomy,  a  work  which  was  exacj. 
ingly  popular,  and  ran    through   several    editions.       His   interest  in 
the   subject  was   not,  however,  of  the  '  knife  and   fork' kind,   lor  he 
was  an   early  student  of   mammalian   palaeontology,  in  the  develup- 
ment  of  which  one  of  his  succes.sors  was  to  be  a  chief  promotor,     Dm 
Wistar's  claim  to  remembrance  rests  less  upon  his  writings  than  upon 
the   impress  which   remains  to  this  day  of  his  methods  of  teacliii- 
anatomy.     vSpeaking  of  these,  Horner,  who  was  his  adjunct  rind  Jnti^ 
mate  associate,  in  a  letter  dated  I'ebruary  ist,  i8iS,says,  "  In  reviewing 
the  .several  particulars  of  his  course  of  instruction,  it  is  difTicult  to  s-ay 
in  what  part  liis  chief  merit  consisted  ;  he  undertook  everything;  with 
so  much  zeal,  and  such  a  conscientious  desire  to  benefit  those  whn 
came  to  be  instructed  by  him,  that  he  .seldom  failed  of  giving  the  most 
complete  satisfaction.     There  were,  however,  .some  parts  of  his  course 
peculiar  to  himself     These  were  the  addition  of  models  on  a  very  Ian;. 
scale  to  illustrate  small  parts  of  the  human  structure  ;  and  the  divisioii 
of  the  general  class  into  a  number  of  subclas.ses,  each  of  which  lie  sup- 
plied with  a  box  of  bones,  in  order  that  they  might  become  th()r<)iit;h!y 
acquainted  with  the  human  skeleton,  a  subject  which  is  acknou  Idged 
by  all  to  be  at  the  very  foundation  of  anatomical   knowledge.     The 
idea  of  the  former  mode  of  instn:ction  was  acted  on  for  the7irst  tinit- 
about  fifteen  years  ago."     We  have  no  knowledge  of  a  colieelion  u: 
.specimens  by  Shippen,  though  it  is  hard  to  believe  that  he  coidd  liau- 
dwelt  in  John  Hunter's  house  and   remained   free  from   the  insatiable 
hunger  for  specimens  which  characterized  his  master.     But  tliee.stab 
lishmenl  of  a  mu.seum  as  an  important  adjunct  to  the  medical  school 
was  due  to  Wistar,  whose  collections  formed  the  nucleus  of  tlie  S|)len- 
did  array  which  you  will  inspect  to-day.     The  trustees,  in  accepting 
the  gift  on  the  death  of  Dr.  Wistar,  agreed   that  it  should  bo  .styled 
the  Wi.star  Museum,  and  now,  after  the  lapse  of  seventy  si. \  \oars,  the 
collection  has  found  an  appropriate  home  in  an  Institute  of  A.natim'v 
which  bears  his  honored  name. 


J5nt\Vistar  has  established  .^.M        ,   • 
^"•'J  l.ospitaI,Ie,  he  reig„o.l  sun  '„?"''     ■'""  '''  ■'^"'^"•'•^-ince.     (ienia 

...aiitie.  of  heart  .J  u..:::^:^:;:'^  li!  'r-  -^  "-^"'"-> 

CaMwell,  "the  ,svvAv,v/,,,;,,<,;,,,,,,,,^^,  ''':""'  "'  ^hc-  language  of  Charles 
"'^"'I'^'r  name  in  our  ranks  cluster  such".f  ^""■^'.''^  "'" '"■-•^"^l^-"  About 
a.u  Rood  cheer,  and  it  stands  to^v  '•""''  "'  ^""'^  '"'^""^•^''iP 
and  social  intercourse.  Year  by  ii,  '  ,  '  "^^  '''  ■'^>"""3''»  <"or  .•./.;// 
;.■:-  to  the  "  Wis.ar  Parties"  (st  1  '  !,'  ''  ^'"'''''^  ""  ^''^  '"^•'ta- 
1"^-  ■"  I'Jnladelphia)  perpetuates  th'  ,nl  ^^"'-''"^  '"""^^'■«"  °^  winter 
cheerful  haunts  of  men."  '  '""'^'"S^  «'  I>''«  Hfe,  "Go  seek  the 

Iltnv  different  was  Hip  „ 

•-f -^  t'-  sui>ject  I  iu.j:'Zs  z::!:::  ""  "'^"-^^  -^^  -xt 

and  throughout  his  life  those  obii,    '  !         "^  ''''''''''^  '-"'^  ^iifinlent, 
-i  su«;.ring  have  so  often  wru.^^     :    r,:^':;^'--'"^^  -'->'  i"  doubi 
f',.  .tn.gs  wuhin  and   fears  withc^.t    ,  "aTs  ,   V  '"  ''''''''' i'^^^^^^^- 
-ul,  on  ulnch  mort.dity  weighed  leav  h        .    '^  ^^^nUe  and  sensitive 
things  were  ,nore  real  than  the  nnt  ,  '        '  ■",     '"  ''^''''^'  ^''^  <■""••  'ast 
le^  "s  a  ...-../  ..,,,,,  .„  ,,,1         •  ^^;;'  -^^;ci;  he  worked.     He  has 
was  a  sort  of  n.e.lioal  prototype    <  !  Z      \       ^  ^'^  '^"'■^'''  ^^'"  ^^''O'"  l>e 
i"gsof  fate  and  the  fulure,    ir^iceoVrf".  "'""'"  '"^  'i-^-^^ion- 
conf.ss,on.  the  so.d's  cry  f„r  inu   rd   L^       '  "'  ■^^"'-'-'^^'i-ation  and 
'-ely  heard.-     Listen  to  hin,        jl"^"''''  "''«'>^  '"'''ke   the.u.selves 
yet  the  watchman  had  cried  the  hi,     '''"/'''■'^' '"''''"' "^""■"'g.  ere 
turbed  .sohtude  giving  my  ^    o      J         '.T  ""    '''  -«■'■  --'  i"  -> dis! 
prayed  fervently  that  I  might  be     ,1  .b      ''f^'^'^^-^-^S  to  my  Maker. 
f ''  '';^'^  ^  '"'-g-t  be  freed^on:  t      ^1:1.  '"  "''^  """""^"-^  -"> 
irom  the  alluren,ents  of  personal  fr    ndshi     7  ''"'''  '"'"agination, 
educat,on,and  that  I  ,nig iu    under  n''    '"'''"  ""^  Prejudices  of 

pennitted  to  .settle  this  q^es'tio     i     i     i  '"""""^^  "^  ^'-"^  grace,  he 
"-■ry,  the  great  and  eLee  H  '  '""  ""''''^•^•"     ^^-v  ^atniliar  i! 

"'■'^  -'•  ^'»'">t">l  of  the  victr  .  f    r^""  "T  "^  ^'"^  ^'''°"«  •'^""^  '"  the 
"■nvhom  both  blessings  rested   '   , '"'."'^^''^^^ever,  was  one  of  those 

f  ■•''  them,  and  reachecl  the  d  'irel  h^^  ^'^  T'"''''  °^  ^'-"  '--i.  1  e 
=>ealtl.  and  fits  of  depression  he  cTr  j  1  ""i  •  '"  ''''''  "^  ^^'^'^  ^^o.Uly 
;eal  and  as  an  original  work  „"  amho"',  "•^  T""''"'''  ■^^"^"■-  -'^'^ 
'=■;  V,— -ty-  I'articularly  dicT  h^e  "  ^T  '  """'  "^"^'''-"  '^ 
^auaMe  preparations,  and  lis  nane  w  .'  '""''"'"  ^^''^''  '"^>"y 

»'  ^  -^-  in  the  anatomical  coll  ct     ^wL'hT       ''^T"""'^^^"  ^^"■^"  ^^^'-^^ 
Ii''l  ^vhat  shall  I  say  of  f  fm.W    ,  '  ^'''■'  "'^"'  »au>es. 

science  wrought  with  labor  and  travail   r  '"'"  '"""''"'"  "^^  '^^ve„  of 


r 


I 


the  pat.ent  spirit,  the  kindly  disposition,  the  sustained  zeal -^we  .l,.!' 
not  see  aga.n  incarnate.     The  n>enu,ry  of  them  alone  remains.     As  ,1,, 
echoes  of  the  eulogies  upon  his  life  have  scarcely  died  away.  I  need  „ 
reconn    to  tins  au.lience  his  ways  and  work,  but  upon  one  a;pect  o, 

characer  I  nK.y  dwell  for  a  moment,  as  illustrating  an  inlluencLfsnV 
udnch  ha.s  attractcHl  n.uch  attention  and  aroused  discussion.     So  f,r ,. 
he  facts  of  sense  were  concerned,  tliere  was  not  a  trace  of  I>y  rrhonis,,,  i,, 
h.s  co.nposu.on,  I,nt  in  all  that  relates  to  the  idtra-rational  no  nune  . , 

hat  del.ghnl  ..,,...,  that  imperturbability  which  is  thedistingui.sl,,,,.: 
feature  of  the  Pyrrhonist,  in  the  truest  sen.se  of  the  word.     A  st.ik,  ^ 
parallel  exists  between  Leidy  and   Darwin  in  this  respect,  and  it  ,.  ^ 
luterest.ng  fact  that  the   two  men  of  this  century  who  have  livul 
closest  n>tercour.se  with  nature  should  have  found  full  satisfact,..,,  ,„ 
the.r  stud.es  and  ,„  their  domestic  affections.     In  the  autobiographin- 
sect.on  of  the  hfe  of  Charles  Darwin,  edited  by  his  son   Franlis    .' 
wh.ch  are  la,d  bare  with  such  charming  frankness  the  inner  tho„:.h,: 
of  the  great  naturalist,  we  find  that   he,  too,  had  reached  in  s,,;,, 
sensuou.s  affairs  that  state  of  mental    imperturbability   in   win.  h   ,' 
borrow  the  quaint  expression  of  Sir  Thomas   15rowne,  they  .stuiclKd 
not   us  />ur  nm/rr.     Hat  while  acknowledging  that  in  .science  .scenfcisn, 
IS  advisable,  Darwin  says  that  he  was  not  him.self  very  sceptic' 1     d 
the.se  two  men,  alike  in  this  point,  and  with  minds  distinctK  ,:r  tl. 
Anstotehan  type,  Darwin  yet  retained  amid  an  overwhehnin,  ace,,. 
nudat.on  of  facts-and  here  was  his  great  superiority-an  extraouin.arv 
povver  of  generalizing  principles  from   them.     Deficient  as  was  tl.i'. 
quality  .n  I  e,dy.  it  was  not  associated  in  him  with  "  the  curious  a,„i 
lamentabe  lo.ss  of  the  higher  aesthetic  ta.ste"  which  Darwin  nxnirn. 
and  which  may  have  been  due  in  part  to  protracted  ill  health,  and  to 
an  alxsolute  necessity  of  devoting  all  his  capabilities  to  collecting  facts 
in  support  of  his  great  theory. 

When  I  think  of  I.eidy's  simple  life,  of  his  devotion  to  the  suuh 
of  nature,  of  the  clo.seness  of  his  communion  with  her  for  so  „,a„; 
years,  there  recur  to  my  mind  time  and  again  the  lines,— 

"  He  is  made  one  with  iiatmc  ;  there  is  hcanl      fj 
His  voice  ill  all  her  music,  fVom  mnaii  i*U-^ 

Of  thunder  to  tlie  son-  of  nighf^fswect  bird  ; 

He  is  a  presence  to  he  felt  and  known 
In  darkness  and  in  light,  from  herb  and  stone, 

Sprea<ling  itself  where'er  tliat  Power  may  move 
Which  lias  withdrawn  his  being  to  its  own." 

Turning  from  the  men  to  the  subject   in  which  thev  worked   hm 
the  past  to  the  pre.sent,  let  us  take  a  hasty  glance  at  some  of  the  devel- 


i;>H,»,„.  fan  i„  „,,„  ,,  »„„„„„„„,„,,  ,„„J,  '  r      „„\"',S; 

Iw.K  <.f  a  n«vx..-ll,ai  will  be  all.    Ji,„  l,e„.ari.  •     !•,  I,  i«  ,  !  , 

i<-  t,icaner.s,  who  gather   up  ears  ciioti.rh  from   tlie  l.nr^. 
rulges  to  make  a  few  loaves  of  breid      ^,„^i,  ,         T, 
list    centiirv       \'.}     ,         ,\  "  ^^'•''''-'  ^''*-'   'Tiatomists  of 

last   ccnturj,— \alsalva,   Cotuiiniu.s,   Haller    Wiiislmv    \-i  -       i- ^ 
Ca.nper.  Hunter,  aud  the  two  Mouros     f  as  'ofl  u      ^  '•''• 

.U.O.,  u.e.ti^/r-r'o^^- 
Nc.  gee.se  they  were,  gleauin,.  an.i.l  the  stubble  of  a  rest  "ed  field 
wlK.n  the  broa.l  acres  of  biology  were  open  before  then,      T   ^se  ^^  e 
the  days  when  anato.ny  meant  a  knowledge  of  the  hum.n  fr-  neV 

.......  a„a.o.-.a,M.e::s-r;r,!^r,:^^:- 

The  determination  of  structure  u-itli   o   ,.;       ^     .1 
function  has  been  the  foundati         f   ,  ^  1     '%l\''  /"--•->•  °^ 
always  have  been  for  "  him  who  ru is  to  re.d  ■      nf  7  T'  "°' 

;;e..  at  the  time  ^r  .on.  clear  :  and'yelV;:;;!;.^ ^  i;.";:^ t;:^':; 
^  onn  and  relations  uutst  precede  a  correct  physiology.     Tie tt    or 
d.nary  development  ot  all  the  physical  sciences,  a,ul  the  corrls  Z  " 
2  -  "ement  of  means  of  research,  have  contribute    t^T^r  1^ 
the  enl,ghten„,ent  of  the  <  geese'  of  Barclay's  witticism      Tate  tl 
progress  „,  any  one  departn.ent  which  has  a  practical    Ipect   such  I 
."  the  anatomy  and   physiology  of  the  nerv..us  sx'stT     TV    ,    ^ 
exuniple.  in  the  third  edition  of  Wistar's  ■' Anaton,  V^     ite  ^    ^^nf;^ 


ro 

>H^r  in  ,s,s,  tlu-  .Icscripti,,,,  „f  tl,.  .-..nvolutinns  U  tl>e  l„ai„,  o„  wlin  :, 
U.-C  ay  a  wl,.,lo  ar„,y  of  special  stu.lcM.t.  a,o  at  work,  n.e.l.eal,  .,„«!. 
...    anlhropol„,,ca  ,  and  tl.e  lu.utions  uf  wind,  arc  ,!,.  ol.j.c-tivc  po,.„ 
•">-"';'K',^;'l  a".l  psycI.oloKical  rcM.arcl,,    -th.  wlu.I.  suhject  is  tin, 
■sposc.   of:       n,e  surface.,,   ,l,e  h,ai„  rcsc-„,I,..s  that  of  tie  n.ass 
tlie  sn.a  1  nUest.ne,  or  of  a  con  .  olute.l,  cyli.ulrioal  tt.l.e  ;  it  is.  the  ' 
aul  to  he  convoh.te<l.      The  hssures  hetvveen  these  convolutions   lo  ,  ,' 
extend  very  deep  n.to  the  snhslance  of  the  I.rain."     The  knoule.iu 
-Kfon   correlated  with  this  mea.re  picture  of  structure  is  l'   '      ' 
pressed,  perhaps,  ,n  Shakespearian  diction,  "that  when  the  brains  u,.. 
jnU^     -■'-•  would  die.-   The  laborious,  careful  estahlislnnent  of  s       ! 
nre  by  the  nrst  two  generations  in   this  century  led   to  those  brill,    ,, 
.scover,es  ,u  ,he  functions  of  :he  nervot.s  systen.  which  have  n 

revo,u,o„,..Hi  medKMue,  I.ut  have  given  to  psycholo,istsahnost  en., 
of  n.etaphyMcs  to  enable  them  to  dispense  with  tnetaphysics  allogc    : 

t   s  part,cularl>-  uUeresting  to  note  the  widespread  d.nen.lence  of 
departments  ,.n  accurate  anatonucal    knowledge.     The    new  ce  r^ 
anatcnn3    parfcularly    the  study  of  the  surface  of  the  brain,  so 
njanly  d.snnssed   in  a    lew  I.nes  by  Wistar.  n.ade  plain   the  p: 
H.t-gand    I-ntsch,  the  careful  di.s.section  of  ca.ses  of  di.seas     „,      , 
.ra.n  prepared  the  way  for  llughlings  Jackso.  ;  and  gra.luallv  a  , 
phrenology  on  a  scienti.lc  basis  has  replaced  the  crudt  notions  o 

nd  .Spurzhenn;  .so   that  with    the  present  generation,  little  bv    „ 
there  ha.-    been  established,  on  a  .solid  structure  of  anatomy,  the!        ' 
at>on  of  n:any  of  the   functions  of  the   brain.     Plxcite  w    h  a 
to.ch,  from  wtl:...  or  fron.  witho,:t,  a  sn.all  region  of  that  n:yst       u 
|u:rf^.ce   and  my  lips  n:ay  move,  but  not  in  the  articulate  exp^!^ 
bought   and  nnay  see,  but  I  cannot  read  the  page  before  me 
ere  and  s.ght  ,s  gone,  and  there  again  and  hearing  fails      (J„e  1 
U,e  centres  may  be  touched  which  preside  over  the^  muscles  . 

without  the  loss  oi  consoousness.    Touch  with  the  slow  linger  m  Tn  e 
he  nutruun,  of  that  th:n  layer,  and  backward  bv  .slow  det^c       r 

siinness,  f  .ick  to  the  oblivicm  of  the  womb 

To  this  new  cerebral  physiology,  which  has  thus  graduallv  .level- 
oped  wth  .ncreasing  knowledge  of  structtne,  the  study  o  ca  ?  f 
d^ease  has  contributed  enormously,  and  today  the  diagnosis  of  ..ffc 

r..c>.      Ihe   uterdepen.lence  and   sequence  of  knowledge  in   v.uious 
b  anches  of  science  is  nowhere  better  shown  than  „,  thi.tverv  M.h  c 
Ihe  facts  obtained  bypreci.se  anatomical   investigation,  from  c     ^ 
ments  on  animals  lu  the  laboratory,  from  the  study  of  uature's  ex  peri- 


ir 


=;;'';::ri;r,--r:z:r;;;t-r::;^- > > 

'"  a  practical  age  this  vast  rl.anK.  Ins  wn„     1  •   ^■''"'''  "«"• 

""•'"1  in  our  ideas  „f  vvh.t  ,,,.1  ^^n.u.^ht  a  crrespo.ulinK  altor- 

whattodoJ-ntalsounattJlt        :;r  ?'  y'' '''"^  ''"''' 

".  the  surface  of  the  brain  has  rJmi  „       ^i  '"'^■'''""^^'''"  "'"  ^"'^"tres 

.siMerahle  .le^ree  of  cert'iin  v    t  1  ,^  't  possible  to  ,„ake.  with  a  com- 

p:.tho.ogy  „  a'i.:te:;  ';;:!■:  ;:;.";ru';"^  ^"■^'^'^""«>'  -•■ 

arc  scarcely  credible  ^    '  '       '  "'-^'"^•^•'•'■'^'••t>  of  which 

"-^"-.tr:*,::::;':;;;:.':-;--- ;.-... 

incrcawl  convolmi,,,,  of  ilic-  |,r„i„  „ "f"  t    „      "'="'-->l.'"'l""-..K-„l  ami 

.':»'.•'.  of  „a.e,„,-s  ..„.,; .:;:  \ ;;  :,r;r;^'  -•^•"  '■>■  'i- 

numite  anatomy  of  the  orp-,,,  l,n.  i  V  twcntyhvc  years  the 

methods  of  cver-incr  .s    fd  ''^■^•".^"'^J--'-'  ^"  --tensive  stndv  by 

mechanism.     IM.e  n^r  3u      n"  nl    '^^     I'""  '"*'  ''^^^'^  '^^  -'"•I">- 
theanatomicalb^^^^;;;    ;^^^::--^7'«-y-^ 

and  complex  connection  oF  th;:::^'^  t^;:^^";"' ='r '•;""• 
tenned,  the  psychical  functions  are  Lrre  led  '      r     7    """  ''"" 

:Va!  conceptions  have  been  c-uld    ,  [^^^"^^^  i'^^  th,,^  n^^cluu- 

Croonian  Ucture  before  the   Z.' S  "  ''''''""'  fn.u.  the  recent 

■-e.l  the  action  and  the  g;; :,':;':  d'  'V  ''^"  '"""'"'  '  ^'''J^" 
upunthecompIexitvoftheceH  mt  ^''-'^7''>P'»-"t  of  intelligence 

the  physical  Lsis  o  no  c^  n^^!!:';:"  '"f  '''  r""^^'^"^"  '^-" 
Researches  upon  the  fine;^.::^;^^  ^r  l!;^^^^,;'^"?"?---- 
conclusion  that  inibecilitv   ,n^„ini   i  '^ereltral  cortex  lead  to  the 

of  insanity  are  but  sy    n  ;      '  '""'f  """^   "''^  ''''  --»->-  '-..s 

cells,  and  not  sep  r^'  He  ioL  oT"''"  •  Tf'"''''  "'"  '^'^  '^^•--"•'»> 
Still   further;  there  i\' ;scw;r    "^^  ^'""^>--  the  mind. 

associate  mor  1  derlntmen    "th  n, "       7f  ^  "^'"'"  ^'^'^-^'^  ^- 

of  the  brain,  and  ur^  f   1     L^       P'-.y-cal  abnormalities,  particularlv 

arevillainsbynecestit /fool    I  V        """,""'  ^"'"'"•^■^'  '"  "''''^''  ""'-■> 

andtreacberAy:^;^,^:^,^     -:^'r-;;^^^ 

i'l  our  knowledge  of  brin   f,^,  i"       ^'"''^ '■^■■"•'^•''^•^''le  revolution 

careful  and  accurate  .s^^;  l^''Chv ^'^^  "'^""f"  r  '''''''  ^^°"'  ^'- 
the  nervous  system      Trnk  ,       ^7"^'^>' "''    ^eese.'  of  the  anatomy  of 

'-..better  ti::;^:;;e  j;:;:^^  is:;^^  °^  ^'^ ''''-'  °^  ^^p^-^-  ^- 

Ihe  study  of  structure,  however  qc  the  h^«;.    f     •*  i    , 

•^« «-« ,.ov.ce  Of  „,..o„„,  }„.„;;  ,r  r;::,-; ;:;  ^„^»-:;;»; 


ill 


13 


I 


,  r?'V  "'■"'  ''""^^''"'  ^'"  """^"-""  manifestations 

.1  ■        "■^•^':  ;\'^""^^'  ^''^-  '^'^^'^  K'nvc„,i„K  tl,.  growth,  .Icvclopna.,,. 
-t.ons  o,    u-.n,  tlnn«s.    Join,  Ilnntcr,  the  nK..lcr  of  Sl.ipp  n  .   ,, 
h      ok.  was  tl,e  fust  great  Mologist ...  tl.c  n-ock-rns,  not  alon '•  l.ca    ,' 
<.f  lus  c.xtraonl,n:.ry   i-oucrs  of  uh.servation   and   tl.c  conn.reh.Ms,. 
sweep  onus  uuelleet.  hut  cl.ieily  l.ecause  h.  fnst  l<,.,ke.l  at     ,1. 
who  e.  „„     studied  all  of  its  n,auifes:at,ons,  iu  onler  and  diso      ;   , 
'-'"■  •■^'•^1  >•■  .hsease.     He  first,  iu  tlu.  words  of  lU.ekle,  'Metcrnun 
t"  -uten.piate  nature  as  a  vast  an.l  united  whole,  exhil.itiuK,  i    , ! 
a    d.ff^rent  tunes,  dillereut  appearances,  hut  preserving  anm  s 
change,  a  pru.c.ple  of  uuitorn,  and  uninterrupted  order,  admitting 

lant>       hut  tn  the  cou.mon  eye  .rrcKularities  ahound  on  every  sid.   ■ 
\\eo    the  n.ed.cal  profession  n.y  take  no  little  pride  in  the    h,      ,a 
here  have  never  heen  wantin,  n.en  in  our  ranks  who  have  tro,,, 

"  i  I.e  . ly,  hnt  n,  a  ,nore  luunhle  way  n.auy  of  the  n.ost  .lili.ent  sL 
dents  oi  hu,loKy  have  heen  physieiaus.      fVon,  John  Hunter  to  Char  " 
mvn,  enorn,ous  progress  was  n.ade  in  every  .lepartn.ent  of  1      ' 
aud  hot  u>y,  an.l  not  only  in  the  accunndation  of  facts  relating  to  stn^:. 
.re,  hut  u,  the  knowledge  of  function,  so  that  the  conceptto    .      ^ 
Phemuuena  ...  hving  matter  was  pr.,,ressively  wi.len.-l.   ^Then    v 
he     ()r,gu.  of  Species"  cau.e  the  awakening,  an.l  the  theorv  o    . 
on  has  not  only  change.l  the  entir.-   ,spect  of  hiolo.v,  hut  has  r    „,  . 
tioni/.ed  every  .lei.artnient  of  human  thought 

Kven  the  theory  itself  has  con.e  within  the  law  :  aud  to  those .  ■  ,. 
whose  hu  ogy  ,s   ten  years  old.  the  new  cone  ptions  are,  perl, 
ht tie  hewd.  ern.g.     The  recent  literature  shows,  however,  a  r  n.ark  .ble 
fcrtduy  au.l  strength.     Aroun.l  the  nature  ..f  cellorgauhation  ,  k 
tie  w.ges  n>..st  fiercely,  and  here  again  the  knowledge  of  structmv 
sough    eagerly  as  the  hasis  of  explanation  of  the  vital'phenomc  S 

r    heal  have  heen  the  changes  i„  tins  direction  that  a  new  an,-.,,,,,. 
ca ted  ternnuology  has  sprung  up,  aud  the  sin>ple,  undiirere,:..a.l 
t  of  protoplasm  has  now  its  cytosome,  cytolymph,  caryosouK.   ,  hro- 
™ie   wuh  the:r  somacules  and  hiophores.     These  accurate  suul^ 
n  the  v,ta    un.ts  have  led   to  material   modifications  in  theth.wv„f 
descent       W  e.smann  s  views,  particularly  ou    the  immortalitN   oi  the 
n.ucelhUar  organ.s.us,  an.l  of  the  reproductive  cells  of  the  higher  f,„  .ns 
ando,.   the   transnussiou  or   non-transmissiou  of  acquired 'han:! 
luve  been  hase.l  .hrectly  upon  stu.hes  of  cell  structure  an.l  celLf...,,, 
iu   uo   ^     .    has  biological   science  so  widened    the  though.s  of 
men  as  mn     application  to  .social   probleu.s.     That  throughout  tl,e 
ages,    m   the   gradn.al   evolution  ..f  life,  ov...-  ..nceasing  purpcse  runs; 


13 

:^::nrs:::  jrr /!:';;:!  !■";:-'- ™"v'^' - « - 

I'lifiUMiiciKi  must  in  iMliiir  l,c  hand  „„  Hk- l,i„lM>,i  •  i 

:;:i:"ru;::'::;::,;:;;:;;7;;:;:::;;::'-*-''";'-'---"* 

r.i  I  •  '"''"•■"'■'"  <'»11'  I'ClSdIls  flic  nxiiU 

'■'  ""■■  '■''"""'""  ^""'  ""  "'^'1  '■ ral  ™u,„v  „f  pas,U.«  .1  ,  H     ,c 

w.  ...a,.  v.,„„rc.  ,„  aH.i..i,,a,.  a  fau.r.  .sonCv  „„id.  „,l?  n  ,    .       „    ,' 
l.ut  which  may  i.„„ii,„R-  u.  make  ,.r....„..  ,  ,,„  ,,,„„.,      ,"""'' 
,      MispuKitd,  the  I        .uilion  rtnu  alt(    t-xacllv  tn  il.p 
iMcncc,  ami  the-  inlaKoinsin  hft«nn  iho  iiKlivichial  ai„l 
ihc  s.Ki,,l  u,„aii,M,i  cxli„K„i5h„l.     llul  ir  the  views  .,f  il„ 
,."vare  in  the  iiian,  ..,„<«:  if  there  catiheL  ;;!':;;  ™^^ 
accntttla  ,.,„  „f  c„„«e„i,al  variations  ahove  the  av'ra„e    "til, 
.ea  of  „  her,  l,el„w  :  if.  „  ah„ut  the  e,„is,a„t  stres,  ol'el    t  „    „"ieh 

;:;sit  t= :?— :^  ;;;f -- p-'-. --::r; 
'-^^,;';-"'.-.v-'--^--'v:re;i::,™.Th:i;:;r,;;Se^ 

1...  ogy  toache,  the  ,,rol,le,„»  of  life  a,  every  poittt.  a„.l    ,„v "    °„, 

o.:':L:r'^:.::::r-;:r,?:e::;;,,r:rxr- 

».-.  „.  this  l,„ti,„te  a  ,„„„„,i,e„,al  t„„wle!lge  of  the  law 'of  lil 


'4 


► 


To  tlie  physician  particularly  a  scientific  discipline  is  an  incalculal .:, 
gift,  which  leavens  his  whole  life,  ^nving  exactness  to  liahits  of  thouj^ht 
and  tempering  the  mind  witli  that  judicious  faculty  of  distrust  whirl, 
can  alone,  amid  the  uncertainties  of  practice,  make  him  wise  unto  sal- 
vation.  hor  perdition  inevitably  awaits  the  mind  of  tlie  practitioiui 
who  has  never  had  tlie  full  inoculation  with  the  leaven,  who  has  nev.r 
grasped  clearly  the  relations  of  science  to  his  art,  and  wh..  knows  n„tli 
nig,  and  perhaps  cares  less,  for  the  limitations  of  either. 

And,  Mr.  Provost,  I  may  he  permitted  on  higher  grounds  to  mi,, 
gratulate  the  Tniversity  of   Pennsylvania  on   the  acquisition  of  Hiis 
Institute.     Tliere  is  j;reat  need  in  the  colleges  of  this  country  of  „,ai 
who  are  thinkers  as  well  as  workers,— men  with  ideas,  men  who  h  ,vr 
drunk  <leep  of  the  Astra!  wine,  and  whose  energies  are  not  sapped  i„ 
the  treadnnll  of  the  clas.s-room.     In   these  laboratories  will  be  -iv,,, 
opportunities  for  this  higher  sort  of  university  work.     The  condrti„ns 
about  us  are  changing  rapidly,  and   in   the  older  states   utility  is  i,,, 
longer  regarded  as  the  test  of  fitness,  and  the  value  of  the  intelkctn  ,1 
life  has  n.sen  enonnor.sly  in  every  department,      (k^rmany  nuist  be  o„r 
m  y.lA  m  this  respect.     .She  is  great  because  .she  has  a  large  group  of 
men  pursuing  pure  science  with  unflagging  industry,  with  .selfdeiuino 
zeal,  and  with  high  ideals.     No  secondary  motives  sway  their  niin.js' 
on   cry  reaches  them  in  the  recesses  of  their   laboratories    "oiwlnt 
practical  utility  is  your  work?"    but  unhampered  by  social  or  the,. 
logical  prejudices  they  have  been  enabled  to  cherish  "  the  truth  which 
has  never  been  <leceived,-tliat  complete  truth  which  carries  with  it  th. 
antidote  against  the  bane  and  danger  which  follow  in  the  train  of  half 
knowledge."     (Helmholtz,) 

The  leaven  of  science  gives  to  men  habits  of  mental  accuracy 
modes  of  thought  which  enlarge  the  mental  vision,  and  strengthens^ 
to  use  an  expression  of  !•  picharmus— "  the  sinews  of  the  under- 
standing." Hut  is  there  nothing  further.?  Has  science,  the  last  gift 
of  the  gods,  no  message  of  hope  for  the  race  as  a  whole  ;  car  it  .hMn. 
more  than  impart  to  the  individual  .  v„„?..,  im]UTtu,l.ability  anii.l  th. 
storms  of  life,  judgment  in  times  of  j.erplexity  ?  Where  are  the  bii-dit 
promi.ses  of  the  days  when  "the  kindlv  earth  .should  slumber  i;,],t"^iii 
universal  law"  ?  Are  these,  then,  futile  hopes,  vain  iniagininos  „f  the 
dreamers,  who  from  Plato  to  Comte  have  sought  for  law,  for  or,!,  i,  loi 
the  av//(is  Dei  in  the  ironiim  /loniiiiis  .' 

Science  has  done  much,  and  will  do  more,  to  alleviate  the  uniiappv 
condition  in  which  .so  many  millions  of  our  fellow-creatures  livr,  ;,i,d 
in  no  way  more  than  in  mitigating  some  of  the  horrors  of  di.seaM-  Imt 
we  are  too  apt  to  forget  that  apart  from  and  beyond  her  (Ioin.,ii,  li,. 
those  irresistible  forces  which  alone  ,swav  the  hearts  of  nu,,      With 


IS 


reason  science  never  parts  company,  I.ut  with  feelin.o,  emotion,  passion, 
what  has  she  to  do  ?  They  are  not  of  her ;  they  owe  her  no  allegiance 
.She  may  stndy,  analyze,  and  define,  she  can  never  control  them    and 

'V  no  possibility  can  their  ways  he  justified  to  her.  The  great'  phi- 
losopher who  took  snch  a  deep  interest  in  the  fonndation  of  this  Uni- 
versity chained  the  lightnings,  hut  who  has  chained  the  wayward 
spirit  of  man.  Strange  compound,  now  wrapt  in  the  ecstasy  of  the 
iHat.fic  vi.sion,  now  wallowi  ,g  in  the  ,ughs  of  i,iic,nity,  no  leaven 
earthly  ,>r  divine,  has  worked  any  perm,  .nt  change  in  him.  Listen  to 
the  words  ol  a  student  of  the  heart  of  man,  a  depictor  of  his  emotions  • 

■  I.,  all  ages  the  reason  of  the  w.nld  has  been  at  the  mercy  of  hrnte 
Mice.     I  he  reign  of  law  has  never  had  more  than  a  passing  realitv  and 
never  can  have  more  than  that  so  long  as  man  is  human.     The'  In.li- 
y.dual  intellect,  and  the  aggregate  intelligence  of  nations  and   races 
have  alike  pen.shed  in  the  struggle  of  mankin.l,  to  revive  again  indeed' 
hilt  as  surely  to  he  again  put  to  the  edge  of  tlie  sword,     l.ook  where 
you  will  throughout  the  length  and  breadth  of  all  that  was  the  world 
5u,,o  or  500  years  ago;  everywhere  passion  has  swept  thought  before 
It,  and  belief,  reason.      Passion  rules  the  world,  and  rules  alone      And 
passion  is  neither  of  the  head  nor  of  the  hand,  Init  of  the  hear'       I  ove 
hale,  ambition,  anger,  avarice,  either  make  a  slave  of  intelligence  to 
serve  their  impubscs,  or  break  down  its  impotent  opposition  with  the 
unanswerable  argument  of  brute  force,  and  tear  it  to  pieces  with  iron 
hands.        (Marion  Crawford. ) 

Who  runs  may  read  the  scroll  which  reason  has  placed  as  a  warn- 
nig  over  the  human  menageries  ;  "chained,  not  tamed."  And  yet  who 
can  doubt  that  the  leaven  of  science,  working  in  the  individual,  leavens 
n.  some  .slight  degree  the  whole  social  fabric.  Re.son  is  at  least  free 
...nearly  so  ;  the  shackles  of  dogma  have  been  removed,  and  faith  her^ 
self,  ireed  from  a  morganatic  alliance,  finds  in  the  release  great  gain. 

<  'ne  of  the  many  fertile  fancies  of  the  "laughing  philosopher,"  a 
happ.v  anticipation  again  of  an  idea  peculiarly  modern,  was  that  of  the 
nil  ne.ice  upon  ns  for  weal  or  woe  of  Ivxternals,  „f  the  idola,  images 
ami  ellliiences  wiiich  encompass  us,  m,[  b;Kternals  upon  which  so  much 
"I  onr  happiness,  yes.  so  much  of  our  every  character  depends  The 
tren.l  ol  scientific  thought  in  this,  as  in  the  atomic  theory,  has  reverted 
10  the  .sage  of  Al.dera  ;  and  if  enviroiiment  really  means  so  much,  how 
all-tn.portant  a  feature  in  education  must  be  the  nature  of  these 
eneompa.ssing  eriluences.  Ths  magnificent  structure,  so  admirably 
■Hlapud  t.)  the  prosecution  of  tl)  t  science  from  which  modern  thought 
I'as  drawn  its  most  fruitful  inspirations,  gives  completeness  to  'the 
:ihva,lv  exhilarating   ;;^,y,W/  of   this    University.     Here,  at   last    Mr 


11 


I6 


I  rovost.  and  largely  owing  to  your  iiidonntable  energy,  are  gathered 
all  the  externals  which  make  up  a  .SV/../«  /.a./.^  worthy  of  this  gnu 
Commonwealth.     What,  after  all.  is  education  but  a  subtle,  slowK 
nfTected  change,  due  to  the  action  upon  us  of  the  ICxternals  •   of  the 
written   record  of  the  great  minds  ..fall  ages,  of  the  beautiful  -,„,] 
harmonious  surroundings  of  nature  and  of  art,  and  of  the  lives   <.„„i 
or  .11    of  our  fellows.-these  alone  educate  us,  these  alone  mouUrth, 
deyelop.ng  numh.     Within  the  bounds  of  this  campus  these  innuen..s 
will  lead  successive  generations  of  youth  from   matriculation  i„  Uic 
college  to  graduation   in   the  special  school,  tlie  complex,  varied  i„ 
.Muencesof  Art,  of  Science,  ami  of  Charity  ;  of  Art,  the  highest  devel,,,, 
ment  of  which  can  only  come  with  that   sustaining   love   for   ideals 
which,  'burns  bright  or  dim  as  each  are  mirrors  of  the  fire  for  whidi 
all  thirst  ;•  of  Science,  the  cold   logic  of  which  keeps  the  mind  i„de 
pendent  and  free  from  the  toils  of  self  deception  and  half-knowled..e  ■ 
of  Charity,  in  which  we  of  the  medical  profession,  to  walk  worthilv  „u,st 
live  and  move  and  have  our  being. 


CL  l_ 


Oliver  Wendell  Holmes 


n 


ItEMARKi^  MADE  AT  TllF    thttju.^    ,. 

lllh  JOHNS  HOPKINS  MEDICAL 


SO,  IET7,   OCTOBER  15,   I8<. 


894 


By 


WILLIAM  GSLER,  M  D 


limi<Uea  fro,,  tke  JoUn.  „,,,,,,  ,,,^^  .,^^  ^^^^^^^  .^_  ^^ 


tober,  1894 


BALTIMORE 
THB  FBIEDKNWALD  COMPANY 

1894 


fFrom  The  John,  Bopm,  Bomtat  JiutleUn.  No  «. October,  -.m.) 


OLIVER  AVENDELL  HOLMES.- 

By  Wir.  OsLEU,  M.  D, 

^       Very  fitting  iudeed  is  it  that  J,e  who  hud  lived  to  be  "  t!,e 
last  leaf  upon  the  tree"  should  have  fallen  poaoef.lly   n 

that   although    he  had,   to  use  the  expression  of  Benjamin^ 

ot  po.tent3  the  freshness  and  ,>liancy  of  his  mind  had  no^  for 
a  moment  faded  Like  his  own  wonderful  "one-hoss  sha  " 
the  end  was  a  sudden  breakdown;  and  though  lie  would  Ime 
confessed,  no  doubt,  to  "  a  general  tlavor  of  '^leeav  "    le 

reusing  of  al     hunum  spectacles,  those  cold   gradations  of 
decay,  u.  which  a  n.an  takes  nearly  as  long  to  die  as  lie  do 
to  growup  uud  hvesasort  of  death  in  iffe,  'Ufa  sinelZ 
mare,  lin  sine  mortemori."    ,--  V 

Enough  has  been  said,  and  doubtless  well  said,  by  those  A7ho'' 
niake  criticism  their  vocation,  upon  the  literal-;  position  :d 
affinities  of  Oliver  Wendell  Holmes,  and  I  sh/ll^pareyo 
perhaps  already  surcharged  ears.'  He  has  been  sandwiched  iu 

Chats  r",  ^'^^^  ""'{  ''-'''  '^^^^^'^"  ^1--  Goldsmith  d 
Charles  Lamb      More  than  once  he  has  been  called,  I  think 

he  American  (.0  dsmith.     Certainly  the  great  distinct  0  1  of 

both  men  lies  m  that  robust  humanity  which  has  a  smile  fo 

Ihe  English  01,  ver,  with  a  better  schooling  for  a  poet  fhad 
he  not  learned  in  suffering  what  he  taught  in  son^)  hid, 
l^ner  fancy  and  at  his  best  a  clearer  note^  With  boH   wdt  / 

z  ;:  L: '°  c  '^ '""  ^^''^'  '^  '^'^  '"^^  ^^"-' «-  ?'- 

merirwh^^\  """  ""'"'  ''"'  ''^'''  I»-««^-writers  of  equal 

ment.who  have  so  successfully  courted  the  "dra<.<.le-f,  led 
Muses,"  as  Goldsmith  calls  them  v  Like  CharrefLamb 
Holmes^ain^e  affections  of  his  readers  at  the  first  siSg,' 

^.•Remarks  made  at  the  Johns  Hopkh.  Medical  Society,  Oetobe.. 


I  !\ 


and  the  genial  humor,  the  refined  wit,  the  pathos,  the  tendor 
seusitiveness  to  the  lights  and  shadows  of  life,  give  to  the 
Breakfast  Table  Series  much  of  tiie  charm  of  the  Essays  of 
Rlia.    y.  •' 

While  it  is  true  that  since  Rabelais  an  '   Linac-re  no  -cneni- 
tion  has  lacked  a  physician  to  stand  unal)ashed  in  the  temi)le 
at  Delos,  a  worshipper  of  worth  and  merit  amid  the  votaries 
of  Apollo,   I  can  recall  no  name  in  the  past  three  centuries 
eminent  in  lUurature— eminent,  I  mean,  in  the  sense  in  which 
we  .-egard  (Goldsmith— which  is  associated  in  any  cndurin-  way 
with  work  done  in  the  science  and  art  of  medicine.     Manl 
physicians,   active    practitioners— Sir   Thomas    Browne    foV 
example— have  been  and  arc  known  for  the  richness  and  ^•a'riet^ 
of  their  hterary  work;  but,  as  a  rule,  those  who  have  remained 
in  professional  life  have  courted  the  "draggle-tailed  Muses" 
Hs  a  gentle  pastime,  "to  interpose  a  little  ease"  amid  the 
worries  of  practice.     Few  such  have  risen  above  mediocrity  • 
fewer  still  have  reached  it.     We  know  the  names  of  Garth  of 
Arbnthnot  and  of  Akenside,  but  we  neither  know  them  'nor 
their  works.     The  list  is  a  long  one,  for  the  rites  of  A],ollo 
have  always  had  a  keen  attraction  for  the  men  of  our  rank^ 
but  the  names  fill  at  the  best  a  place  in  the  story  of  the  litera- 
ture of  tlie  country,  not  a  place  in  the  hearts  and  lives  of  the 
people.     Far  otherwise  is  it  with  a  select  group  of  men  Gold- 
smith, Crabbe  and  Keats,  vA   the  outset  members  of  ,.,',r  pro- 
fession, but  who  early  broke  awav  from  its  drudgerv.  In  pride 
we  claim  them,  though  in  reality  no  inlluence  of  their  si»trial 
studies  IS  to  be  found  in  their  writings.  Two  of  these, at  least, 
reached  the  pure  empyrean,  and  to  use  Shellevs  words,  robed' 
in  dazzling  immortality,  sit  on  thrones 

"built  l)eyond  mortal  thought, 
Ivr  in  the  Uniipparent." 

Oliver  Wendell  Holmes  may  not  reach  the  same  exalted 
ejihere,  but  he  will  always  occupy  a  unifiue  position  in  the 
ali^ections  of  medical  men.  Not  a  practitioner,  yet  he  retained 
for  the  greater  part  of  his  active  life  the  most  intimate  con- 
nection with  the  profession,  and  as  Professor  of  Anatomy  at 
Harvard  University,  kept  in  touch  with  it  for  nearly  forty 
years.     The  festivals,  at  Hpidaurus  v  '.'e  never  neglected  by 


^nnn,  tl.e  ninetoentl.  cen  ury  tl   oe  scho  ,         ''""      • 
liiive  luouldeiUhe  tJio.Kdif.  .,,,,1    ,  .         '"  "^"^'cession 

fession  in  fins  con.     y"       /        T'""^  "^  ^''^  •"^'^'•■«'^'  m'o- 

American  st„den"w:^:,,t'"';f"'r-  ^f^-'^  ^o  .h.u 

school.     .Since.   KSflo  the     ,  h        "      \    eadungof  tlie  French 
been  ull-powcrf  ]  L    of  ;"  "'  ''"'"""  '"^'J'^--'  J'- 

a'xl  that,  when  .....sibie  fh  "''^  ''o  trnly s„el,, 

in  France  and  Kngland         '  '  ''"""^  •""   '^^^''^-  ■^^-''^■^ 

st.^^h^'^;?eSj^,;Xn:?'^  'f ?■  ^^  ^"""^  ^"-•'-- 

Hohnes,  Jana^s  .,a  kso        r    T     '"'"',  \f  "^^-^liver  Wendell 

Hnd  Stille,  from  Phil-  de  r,.^  '  f T"  ^'''  ^  "'■'^•'  ^'^^''^-'ini 
They  broukt  back  ott^^' ;''''^  ^ '^^'''■'  ^''""^  J^'^ltinu.re. 
and  habits  ..         'rate  l.  ^^  '"  "^'"''''^  ''''"'''''  ''  --!< 

-.'.t  also,  w;::;'^:^  t  :t:>;fT:r';';"'^"'^^  ^"^^"-^ 

inspiring  enthusiam.  80  T  s  H  o  "  ;  '""^'  '^  '''^ 
American  pupils  reni-uii/ fnl    V        '  •""' ^^""' «^  J^«"i«"« 

Ht^,oftLkive:-;;'s;::::.:^.s-^^-— ^ro. 
^ienisridrd^^iifk:^^^^^^ 

to  his  class  in  18Sa  is  Hr<  .K         '  ™l*'dictory  lecture 

old  Paris  teachers  ^    ^'  ""^^'  "*>  of  ren.iniscences  of  his 

evid^t^'hJ^/^r^/-^--^^l  e,u:p.ent  is  verv 
1830  and  1837  eCl  in  "'^  to  medicine.  In  the  year^ 
Boylston  priJs,  it't!;  --^""y  competing  fo/ the 
^El^^a,  on  ^e;„.algia:X  ;f^^;:;;;^^;^^^ver  in  New 
of  Direct  Exploration  ;„  Ar  r  1  ..  ^  '  Jmprovemeut 
™«yoni„te™i,"r   ,',';':','"=''";    "'  "-e  H,o 


'■I 


i  ! 


; 


purpose  he  infide  ii  careful  and  thorough  examination  of  the 
records  of  the  first  century  of  the  aettleinents.  Here  and  there 
throughout  the  essay  there  is  evidence  of  his  irrepressibh; 
humor.     Referring  to  the  old  w  iters,  he  says,  that  because 
indexes  are  sometimes  imjierfect,  he  has  lool<ed  over  all  the 
works  page  by  page,  with  the  exception  of  some  few  ecclesias- 
tical papers,  sernujns  and  similar  treatises  of  Cotton  Mather, 
"which,  being  more  likely  to  cause  a  fever  than  to  mention 
one,  I  left  to  some  future  investigator."    The  essay  shows 
great  industry,  ami  is  of  value  to-day  in  showing  the  localities 
in  which  malaria  prevailed  in  the  early  part  of  this  century, 
and  at  the  time  at  which  he  wrote.     The  essay  on  neural- 
gia is  not  so  interesting,  but  is  an  exhaustive  summary  of  the 
knowledge  of  the  disease  in  the  year  1H3(;.     The  third  disser- 
tation, on  direct  exploration,  of  much  greater  merit,  is  a  plea 
for  the  more  extemled  use  of  auscultation  and  percussion  in 
exact  diagnosis.     The  slowness  with  which  these  two  great 
advances  were  adopted  by  our  fathers  contrasts  in  a  striking 
manner  with  the  readiness  with  which  at  the  present  day 
we  take  up  with  new  improvements  and  appliances.    Aven- 
brugger's  work  on  percussion  dates  from  17G1,  but  it  was  not 
until  the  beginning  of  this  century  that  the  art  of  percussion 
was   revived  by   Corvisart  and    Laeuuec ;  while   Piorry,  as 
Holmes  says,  succeeded    in    creating    himself    a  European 
reputation  by  a  slight  but  useful  mod.llcation  in  the  art, 
referring  to  his  pleximeter,  of  which  in  another  place  he  says 
that  Piorry  "  nuikes  a  graven  image."    The  great  discoveries 
of  Laennec  make  their  way  very  slowly  to  general  adoption, 
and  to  this   Holmes  refers  when  he  says,  "it  is  perfectly 
natural  that  they  (speaking  of  the  older  practitioners)  should 
look    with    suspicion    upon    this    introduction  of    medical 
machinery  among  the  old,  hard-working  operatives ;  that  they 
should  for  a  while  smile  at  its  pretensions,  and  when  its  use 
began  to  creep  in  among  them,  that  they  should  observe  and 
signalize  all  the  errors  and  defects  which  happened  in  its 
practical  application." 

Gerhard's  work  on  the  diagnosis  of  diseases  of  the  chest  was 
published  in  1836,  and  with  this  essay  of  Holmes's  opened  to  the 
American  profession  the  rich  experience  of  the  French  school 
in  the  methods  of  direct  exploration  la  all  disorders  of  the 


clii'St  unci  of  the  heurf      irni...    • 

by  the  student  wrL;;,  T'"'  '"?  '"  ""*^  '"''''y 
original  references  to  the  1^  tii;  s"  j^^^'^^^^jy  neH  in 
crat  and  of  others   of   H  '  ii*^'iders  of  the  ^«^o- 

-rprised  at  til  r:dines  with  IV^f^^^^^^^^  ""''"  '^'^^^  '-" 
the  fathers  of  the  n  ofe  i^  If  V^" ''''?^^^^  "^''  ^'^^^'^  to 
those  Boylston  1,^^,1,'^  'T'^  "^J'^^'"*^''  ''^ 

had  evidently  t  di  not  t^^^^^^^^^  'ntheir  preparation  he 
'<lav,  but  he  had  .one  n  th.  o  "^  .  "l?^"'"  ""^^"''^  "^  ^^^ 
Hippocrates  to  Harvey  ^'"       "  *''  ^'"^''^  ""^^^^^^  ^^om 

i;  in  so.e  resp^t  o;::J  ^t;t:t7ZT  ""  ^^^^"^^ 
Hoylston  essays,  vet  we  conl.l  J       ,    f  ^  '°"^'  "'"''^^  of 

reputation  foJ  DrHo  ^  t  ■' >^^  '  '  '^"'''"  "^  '  "'^^''^'^' 
productions.  ■  A  few  vt.  tl  ",  ''  ''''  "l'«"  ^'^^^^  ^^rlier 
article  which  will     nfk    J    "■'    ^^''"'■'  '^*'  ^""^"^^"ted  an    ^ 

Child-hedfever\^^^un  In^  "''""'■^^''"■"  '"  ""•  '■''''^'• 
Wendell  Hohnes  sh  dief  ^  ind' .'ir"  v "'"  ^^^  «^-er 
who  had  proclaimed  rd 2  ^^J^V'T  ";"""=  •""' 
highly  contagious  nature.  Indeed  so  ff  IT'  ''"'^  ''' 
of  Aberdeen,  not  only  ca  led    t  •  "'    '  "'  ^^'^'  ^'"'•^*^"' 

he  could  predict  rth''';'  '  «P^«"^^  ^«"t.gion,  but  said 
m.rses  in  who  e  pr  "ti  '  ,  '^^     ^'^^"^'^5^  ^^e  very  doctors  and 

^-nent  the^snriJir  s:^^^t^:^:,  li^^^^'-^ 

fhut  doctors  ;rZ:e?couhfco;'^^^^^^^      ""^'^^^  ^^^  ^^- 

weis  had  not  the^    e'un  to  ll  T^    1  ''''"^"-     ^"'^'"'"^l- 
«ive  observations  f or  w  1  e  ,\  '  "^^^'''^^^'^g  '''"J  conclu- 

greatly  honored  '''  ^'^  '"""'^'•y  ^''^'^  ^--"y  been  so 

In  1843,  before  the  Boston  Society  for  Medfp.i   r 
'"ent,  Dr.  Holmes  read  a  paper  entitled  -Pblp  P'"°'" 

of  Puerperal  Fever"  in  wiS  f      Contagiousness 

-ayofLtsinir^po;  oT  evit  ra^f^^^  T'"''  '  ^^"^ 
^Hgious,  conveyed  usually  by  the  Lcto  r  H l  '''  '''?'"■ 
to  a  specific  infection  Af  th!  7^*^^^  "'^  "^^  ^"^se,  and  due 
="'  article  in  which  Z'sutlf  ''  ^^'''  ""''^'"'^  ^^^  "«t 
-  convincing  nnn        ft^lT'T  "'  "  ^"^"^'^^^  '^"^ 

-Who.;?  .,.,4--^--;^,;^.^ 


( 


6 

loudly  mu\  8.)  clearly  timt  he  compeiH  i„.„  u,  hear  him-  it,  \, 
to  hiin  thill  the  credit  beloi.crs;  uud  ho  far  as  this  country  is 
.•..neerned   the  cre.lit  of  insi^iing  upon   the  great  practical 
ruth  of  the  contagiousness  of  puerperal  fever  belongs  to  Dr. 
Ilon.es.     J  he  essay  is  characteriml  in  phices  by  intenseness 
=ind  great  strength  of  feeling.     He  savs  he  could  not  for  a 
moment^  consent  to  make  a  cjue><(ton  of  the  momentous  fa.'t 
which  should  not  be  considered  a  subject  for  trivial  diseus.iun 
iH.t  whicli  should  be  acted  upon  with  silent  promptitude.    •'  No 
uegative  facts,  no  passing  opinions,  bo  thev  what  thcv  may  or 
whose  they  may,  can  form  any  answer  to"  the  series' of  cases 
"ow  within  the  reach  of  all  who  choose  to  explore  the  records 
of  medical  science."     .lust  l.efor..  the  conclusions  the  following 
•■loc,ueut  j.aragraphs  are  found,  portions  of  which  are  often 
quoted:-" It  is  as  a  lesson  rather  than  as  a  reproach  that  J 
call  up  the  memory  of  these  irreparable  errors  and  wron-^s 
No  tongue  can  tell  the  heart-breaking  calamities  the-  hau' 
caused;  they  have  closed  the  eyes  just  opened   upon  li  new 
world  of  life  and  happiness;  they  have  bowed  the  stronc^th  of 
inanhood  into  the  dust;    they  have  cast  the  helplessiR.ss  of 
lutancy  into  the  stranger's  arms,  or  be.,ueathed  it  with  less 
cruelty  the  death  of  its  dying  parent.     There  is  no  tone  deep 
enough  for  record,  and  no  voice  loud  enough  for  warnii,.' 
I  he  woman  about  to  become  a  mother,  or  with  her  new-boni 
infant  upon  her  bosom,  should  be  the  object  of  tremblii.o-  care 
and   sympathy    wherever   she   bears    her   tender   burdeii,  or 
stretches  her  aching  limbs.     The  very  outcast  of  the  street  has 
pity  ui.on  her  sister  in  degradation  when  the  seal  of  i.roniised 
.naternity  is  impressed  upon  her.     IMie  remorseless  vengc-anee 
oi  the  law  brought  down  upon  its  victims  by  a  machirn'ry  a^ 
sure  as  destiny,  is  arrested  in  its  fall  at  a  word  which  reveals 
her  transient  claims  for  mercy.     The  .solemn  jirayer  of  tli,. 
iturgy  singles  out  her  sorrows  from  the  nuiltii.lied  trials  of 
Utc,  to  i)lead  for  her  in  the  hour  of  peril,     (iod  forbid  that 
any  member  of  the  profession  to  which  she  trusts  her  lif. 
doiibly  precious  at   that  eventful   period,  should   regard   it! 
negligently,  unadvisedly,  or  selfishly." 

The  results  of  his  studies  are  summed  up  in  a  series  of  eiiilit 
conclusions,  and  the  strong  ground  which  he  took  may  l,o 
gathered  from  this  sentence  in  the  last  one :     "  The  time'  Ins 


r'ori.f  wli.'.i  Mr.  existence  of  a  private  i.t'sfil...,      •     . . 

Medicine,  ...L.e:;:!ea^::;S;ir;::^ 

nients  were  too  bold  a„d  the  wiiole  tone  too  .       i  '" 

arouse  the  antugonisn.  of  those  wh  s  1-  li.  ;  'I';'  '""  /" 
years  diametficallv  onnoKo.!  tnii,  '''-''^"'"Ss  li.ul  been   inv 

fever.  ■•hiladelpLil/n^.^;^:';?'^"?  "'  ''''''"''' 
in  obstetrics  in  L  .oun.^  l:;!^];  ^  ^I^;:V:u  7"' 
American  school  of  oUstetricans  it  i.  dn     o  tl !    .o  <    T 

professors  of  tliis  branch  in  that  citv  Z  f  I  P  "^  '''" 
nu-tnory  of  the  n,en  we  .-on  d  I  t't  "'  "  '''-7'  ^'"^ 
which  I  will  now  allude.  ^M>»>'>i^ed  the  uieident  to 

In  J 852   the  elder   Tr.i,l,r,>    i>.    c  ,.  ^^ 

University  of  PeXlI^fp  S^..:^  ^'^^^^^'^  '^^  ^''« 
contagious  character  of  PuJr n  ■  I  f  /  /''  "  T'  ""^  """" 
a  Meigs,  I'rofessor  of  Vbt^t  .:;,''  '"  '''''■^  ^"""''-^ 
(•ollege,  published  a  work  on   h     nt're  'T  ''"'"'"' 

of  child-bed  fevers    in.     ".       V    !      '     ^"'' ™'^  *^"^'''t'''^'''t 

of  his  class,     no  ^o    the:  em  :  tt  r'";' r''  -^^     '''  '^""'""^^ 
fessors  of  ol>stetric,s  in       ,    H      ',  ,^f.  'T'  '''^^'-'S-i^l'^l  1-ru- 

Hoin^^uui  Meigs  hani;:';-i;:;;L:f:r;;r'^^''^^"'"^^ 

D    1-1  T,        •■'  '^''■'""o  't  ruvrnmtl  Fever  nv  „   /v;„„> 

t.o„   which  pmhicrf    thi,  e»*.y.-'n,V     ,?,"■'""■" 

,.       .  ^  V   I'^jBiLuuis  am    nurses      /^iqj-u      rm 

llKV  »„ld  ever  carr,  .ho  horril*.  ,i,,r-„fj\  ;:';'"'"' 


8 

The  iulrochution  to  li.e  .snay.  wliid,  wu«  renrinted  us  il 
Weaml  .„  lH-l->  is  o,.o  of  tlw-  uhlo.t  and  mo  t  trencll 
IHeces  o  wntu.g  witl.  which  I  am  m.^uHintol.  There  r 
«en,raUtnk.ng  paragraph.;  thus,  in  alludi,,,  to  the  .tro  ^ 
ad  pornonal  hm-M.age  .used  l.y  Afeigs,  Ilohnos  Hay« :  "  I  take  no 
oirence  and  atU-n.pt  no  retor(  ;  no  n.an  n.akes  a\,uarre  with 
n.e  over  the  counterpane  that  covu.  a  mother  wi L  her  m'w 

not  to  Ik.  deceived  by  (I,,,  statements  of  the  two  dlHtin^Miished 
Fofessors  which  seen,  to  h„n  to  enconrage  professioLn;:!;:;! 
-lUt.  One  paragraph  has  become  clasaical:  "  Thev  n'ltnr.llv 
have  faith  in  their  instrnctor,  turning  to  then  /t  U  J 
tHk.ngwintt  they  may  choose  to  give  then.;  babies  in  k  ow 
-Ige,  not  yet  able  to  tell  the  breast  fron.  the  bottle,  pumni  I 
uway  fo,  the  ndlk  of  truth  at  all  that  oifers,  were  it  rloSl 
bettei  than  a  professor's  shriveled  fot-eflnrrer  " 

The  high  estimate  in  which  this  work"  of  llohnes'  is  held 
has  frequently  been  referred  to  by  writers  on  obstetrics. 
,         .Some  year^^  ago  in  an  editorial  note  I  comn.ented  upon  a 
qi.OHt.on  winch  Dr  Jlolmes  had  asked  in  his  "  Hundred  1)  J  i, 
Europe.       Somewhere  at  dinner  he  had  sat  next  to  a  suc- 
cessful gynaecologist  who  ha.l  saved  some  hundreds  of  lives 
by  his  operations,  and  he  asked,  "  Which  would  give  the  mo 
afsfactmu  to  a  thoroughly  humane  and  unsellsh  beinj" 
c  .1  .vated  ,nte  bgence  and  livelysens-    iv  es:  to  have  wrU  en 
a      he  p  ays  winch  .Shakespeare  has  1  ->      an  inheritance  for 

K ui  a  hundred  fellow-creatures,  and  restored  them  to  sound 
and   coiufortable  existence:-"'     I    remarked  that   there  was 

Woer.T  T  !  Tr'  '^'''  ^^"^'^"^'^  ^«  satisfactorily  as  the 
An  ocra  and  asked  from  which  he  derived  the  greater  satis- 
uction,  the  essaf,onpucrpcmlfcver,which  had  probably  saved 

r^^7^^"'^,  """  "'^  "'^^'^'^'^^^^  ^T"^'cologist,  or  the 
Ua>M  M!us,  which  had  given  pleasure  1o  lo  many 
housands.     The  journal  reached  Dr.  Holmes,  and  1  read  you 
his  reply  to  me,  under  date  of  January  21st,  1889- 

"  I  have  rarely  been  more  pleased  than  by  your  allusion  to 
an  old  paper  of  mine.  There  was  a  time  certainly  in  which  I 
wonld  have  said  that  the  best  page  of  my  record  was  that  in 
which  1  had  fought  my  battle  for  the  poor  poisoned  women. 


p:s'.st:'l."or,':x:^;:,':-'  "■ ' ■ »» 

therefor,  cca,  c,l  tl,„  wi  ,  """  >'"''"  '•''•  ""J 

".y.olt  which  „„.i;:;,  ^'^,'',  "7;  "'  •  l.h™,e«  .i,„„t 

I  f"rg,-t  which.  ■       '- '  '""  "  ■  ''»'')•  »!■  '-'lity. 

!-">  »f  .nine,  H,o„«h  ,  w  J '";;„""  I,,;;'  »  '»•"'•'"■ 
coines  up  „t  long  !„(„.„  ,,     ,.,,        "'Jstlt.      r  !,„  „s„j.  „„| 

».«n.ory,  ,.,„,  i/v„,    ,    '  '  ,",71,:?""'  "«"  '"  ">>■ 

h;  torn,,  „,  „,„„1„„,.  „r  ;  '^,    ■■■;-™-,"..,.io„t,, 

pli'as u re,  i  confess  it.  l..,.,  ii-       -/  '      *^'     ^    '"'''   u  siivaw 

to  me,i„  their  ;,,c!o  '"'■'■'  '"'  '"'^'^■^'  '^'^  ■*  ^^'^mecl 
writing  the  ocm  4s  fl  :T'''';f  ""^^'^''-S-  Hut  in 
highest  state^of  ,,ent,U  V  •  "'^\\.''^""''  feoling-the 
clairvoyance,  as  i  "« tf  ^^^^^^^^^  -^«^''"'- 

to  n,e-I  mean  tlmt  lucid  vi2n  nf  .  .  ''"  -''"•^"^ 
forms  of  expression  wJclwil  ,     '"' '  '''""^^'^^  '^"^^  "•' 

whiel.  is  the  pXnei    "i  :l"'"'^'r 
"mount  or  value.     There       n     '     Tu''  '''■^'-'  '''•  «""'"  •« 
out  of  the  noem-perh^^         n    ''"'^  P^^''^'"'^'  ^^  ^'^'  ^'"'1 
saving  labor."         ^       ^^^  "  ""'^'^"'  ^'^^'^'''^'tion  from  the  life- 

referring  to  the  subjeet  in  very  uu  cHli  '  "  "  "'  ''"-"-^ 
nm  in  his  letter  to  L.  oIIm  two  o  Tb  '  ^'"'^'T  ''  ^'' 
quote.     "  Still  I  was  att-irkll  '  P'^'-agraphs  f  may 

'-„.  p.re.„.r;is:;::  i:'s  otir'"  '^ '""  "™ 
not  !v?tt' :t^st;v:"aV'T  r-'r''''^''«""-'"">' 

-t,.a„.o'rt,tr:t.;:?:\-r:^^^^^ 


II 


tOi-^v-. 


A^.. 


''1 


^3^^H 


10 

might  a-ainst  the  terrible  evil,  before  I  did,  and  I  sravo  then, 
full  credit  for  it. 

"But  I  think  I  shrieked  my  warning  louder  and  longer  than 
any  of  them,  and  I  am  pleased  to  remember  that  I  took  mv 
ground  on  the  existing  evidence  before  tJie  little  army  of 
microbes  was  marched  up  to  supjjort  my  position  " 

Fortunately,  Dr.  ilolmes's  medical  essays  are  reprinted  with 
his  works.     Several  of  them  are  enduring  contributions  to  the 
questions  with  which  they  deal :  all  should  be  read  carefullv 
by  every  student  of  medicine.     The  essay  on  Homeopathv 
remains  one  of  the  most  complete  exposures  of  that  therapeutic 
fad       There  is  no  healthier  or  more  stimulating  writer  to 
students  and  to  young  medical  men.     AVith  an  entire  absence 
of  nonseiise,  with  rare  humor  and  unfailing  kindness,  and 
with  that  delicacy  of  feeling  characteristic  of  a  member  of  the 
Jirahnun  class,  he  has  permanently  enriched  the  literature  of 
the  race. 

Search  the  ranks  of  authors  since  Elia,  whom  in  so  manv 
ways  Holmes  resembled,  and  to  no  one  else  could  the  beautifn'l 
tribute  of  Landor  be  transferred  with  the  same  sense  of 
propriety : 

"  He  leaves  behind  him,  freed  from  grief  and  fears 
Far  nobler  things  than  tears, 
The  love  of  friends  without  a  single  foe, 
Unequalled  lot  below." 


OLrV'':U  WENDELL  HOLMES  AS  PHYSICRX 
Thk  greater  glory  of  Wendell  Holmes,  the  writer  of 

classical  prose  and  poetry,   has    for  the   most   part 

eclipsed  his  record  as  a  physician.    Yet  his  purely  pro- 

fessional  wo.k  had  in    its  time  no  mean  share  in 

guiding  current  medical  opinion  to  sound  conclusions 

on  various  points  of  importance.  This  aspect  of  the 
like-work  of  the  distinguished  American  has  been  ably 
(li^cuescd  by  Dr.  William  Osier,  of  Baltimore  W^ 
learn  that  m  18.30  and  1837-shortly  after  his  return 
Ironi  thel'arisian  schools-young  Holmes  distinguished 
hmiself  by  wmning  several  of  the  Boylston  prizes  in 

.succession.    The  subjects  which  he  chose  for  his  theme  ~" -~- ~— ^ 

we^e  Intermittent  Fever  in  New  England,  Neuralgia,  "f"^^™'  '^^^  they  .should  observe  and 

intermittentfever  contained  a  tb:rr;urry:fff-P-ise^^^ 
the  views  and  observation  of  earlier  New  England      '  "^ '°"'^  --espects  one  of  /hi 
writers,  and  are  of  value  to-day  because  they  show  th«  ^  ''"''  °^  ^^°ylston  essavs  '-   t         ''"^ 
localities  in  which  malaria  was  then  prevalent     -^£'  «°J.--  embarked  uZanotT'^r  ' 
essay  on  neuralgia  contain,  an  exhaustive  review  of  I  ''^''^  ^^«  ^^Weved  solid  aS,    ? 
all  that  was  known  of  that  malauy  in  the  vea   1  H3f-    '"*  *'"'e.  strange  as  if^  ^'*'"^ 

lTi,afi.,VH^,o<,».f„*:„_  .,.-.       ,.     '      -    ^  ^'''- ichera  of  hi     ^         '*  "^^  now  seem, 


The  third  dissertation^  tha.  ondirecfe^^^::  ^^f  ers  ^'' ^^^"^^^yi:Z;7:T 
us  back  to  an  interesting  epoch  in  practical  medicine     '''"' '""''^  be  conveyed  bvl.  f  ! 

It  may  be  briefly  described  as  a  plea  for  the  mo  Hx  .^''"'"'■^-  J"  ^'^^'Tr  Hnl  Tf°'^ 
tended  use  of  auscultation  and  percussion  as  metodsr'?;''^^  -^^«'^-'  l4  ov^^  TVefr 
of  exact  diagnosis  As  Dr.  Osier  aptly  remarks,  the^' ^°"*«gi°"«ness  of  I^ZSl  ,  f  » 
slowness  with  which  these  two  great  advances  were''^"''^'' *^<^  theory  that  the  c.  p.  ' 
adopted  by  our  fathers  contrasts  in  a  striking  LZ>  ^'^^^^  ^^«  of  a  powerful  td  In  '''? 
with  the  readiness  with  which  at  the  pre.sent  day  we^?.^""'^"^  lay  i„  the  manLrt  uK 
take  up  new  improvements  and  appliances.  Aven '°''°"  °^  ^^'^  ^"""trymen  to  an  inr 
brugger's  work  on  percussion  dates  from  i~ri    k  ?  *^^  "'most  practie;,!  ;   "  ^°  ^"  ""ecog- 

... ...  a.ti,  fc  be«i..i.,  of'.'hi,'r.„ ;  l'."  t "» "tuud/r  '  i7r.r  ■ "'; 

art  of   percuss  on    was    revived    hv   n      •     !         -fi  "gs  had  for  ,,«„     u  ^^°'''^'"  of 

Laennec  ;  while  Piorry,  asTf^t  l.'ri^  .!"   -ta^iouttt^^r.  !!lf ^ 


I  Laennec  ;  while  Piorry,  as  Holm,  s^ys;™  ^d"   -^^^---  oT^       ,  r  "^  ., 
creating  for  himself  an  European  reputa  ion  by  as  •  .it'^''^  "'^  t^diously.'an^t  en  t        ^^' 
Imt  u.seful  modification  in  the  art,  referring  to  li"^  ^^'^  "^^'^f  opp'inel  t^o  m 
1  eximeter,  of  which  he  says  in  another  place  tha^  '''''  ''^^  of  the  Tatter    n 
J  lorry"  makes  a  graven  image.'  The  great  iiscoverie  '"''  "to  divest  their  mind      .    . 

a    tact   which    Holmes   explains    in    the    fnllLin^    °'^^''' ^^r.  Hod.'e  sair?  ^f  li  ' 

passage:  "  It  is  perfectly  natural  that  they  "spaS^ '°  ^"""^"te  t^^^^^^^^^^^^  '^'^^^ 

of  older  practitioners    "  shn<,]H    l^.t       I^     '^        °^  Ii -h  I  can  fnr,.,  accident  or 

upon  tUi,  i„„oduoti„„'„r  it,  mi:.farr  r'»°  »'  ""■^l  I  caLr;:''''™'  ""«' 

'e  literature  of  the  q^e  tion"  ^.^  contributions  to 
l^r  forty  years  Dr.  Ho  m"  fi,  d'the  "'/^^  ^'^^^  '''^■ 
of  Anatomy  at  Harvard  TTn.-vil  /^'  ^?^  "^  ^'^fessor 


of  Anatomy  at  Harvard  I  nivr.t  ""T  '^  ^'™f«««or 
he  was  able,  to  contribute  "  If  f'  '"'  ■''  ''''  «'^t 
and  art  of  medicine  in  the  m  dst  j?r'  °^.  '^'  ''^'^^' 
>«  no  small  testimony  to  th  et^n".  '''. '''"''^^^  ''^« 
;vbich  has  placed  him  amongX  f''  °'  '^'  ^'^°'"« 
tlie  century.  "^  '^^  foremost  writers  of 


"■■^   praolieal  amJica'lo.  »     T,""  "?'''''  '"''l""""  i" 

undoubtedly  of  frrpnf ,..,  "   •  '^^''^^  ^^^^ys  were 

been  described  as ''n' '"''''  '"'^  '^'^^  ^"  n^alariahas 
best  of  the  longs  riesorv/r^^*'^  °"^  °^  '^^  ^^^ 

cal  .subject,  in  which  .??''' "P°°  ^"^tJ^^--  '"^di- 
renown  ^  thartJn.p  T/'^''"''^  '°'^^  ^"'^  '^^'ing 
t'.e  leading  teacl L  f'  Sl'T^  ''  ^^^  --  seen' 
that  puerperal  fever  coulrl  I  ^^  ''°"*'^  *^^  ^^ea 

nurses  to  their  vZT'^ ;::rf:' ^ l^^^^^r.  and 

the  Iloston  Society  for  Medical  '  ^^'^'™^«>  before 

paper  upon  ^' The  Oonf«^  Jtuprovement,  read  a 

-  ;vhich\e  3uptortTdix:;th:;"trr' ''''-'" 

contagious.    His  essay  was  of  1  n        .  , '''''"'"  ^^« 
nature,  and  its  great  meHM.    •    .f  "'"'^''^  ^"'^  '"g'^al 
he  drew  the  attenttn^f  ^      ^  '°  *^'  "^^'^'^^r  ^^  which 
nised  point  of    he  -Los?''  '^°""*?™«"  *°  an  unrecog- 
bold  and  resolute  attitu.f "'"!;'  '"^'^^^t^nee.     HLs 
those  whose  tea  hing       fj""'^  '^'  -^^^onisn.  of 
opposed  to  the  contaiulss  of     '  ^''°  diametrically 
controversy  dragged  on  tl?     ,  ^"""P"""'  ^^^^'•-    The 
-e  still  find\n.o'4his  chtS;"'.  '''  ^^"^  '^'- 
of  obstetrics.    In  uS   on.    FTT'  ^""^  Professors 
begged  his  students  ""toditftJ:""'-^;-  '''^''' 
dread  that  they  could  ever  carry  theT  ""-u'  °^  *^^ 
while  in  18,54  the  other  Dr  r  ^  "'"'''^  ^"'us  "  ; 

of  deaths.  .'I  prefer  to  atfrKirtr'f  ^'  ^'^^^  ^^^^ 
Providence,  of  which  lean  fnl  ^°  ^"^"^ent  or 

than  to  a  contagion  of  winchr      '  ^"""^^Ption,  rather 
idea.'    The  issue  oJthedtl.  '^°°°t^°rni  any  clear 
position  of  Ho..„e.s,  ^ho    tirstit^i^f '^ 
by  American  writers  on  obste  ri  L  ''^u'^  '''^^''^d 

essays  have  been  reprinted  and  «!'  ?  .'"^"'^  °^  ^''^ 
a«  that  or,  homo^opItV  at  enl  ''"  °^  '''^"''  '^^^ 
the  literature  of  the  o/.e.H  ?  contributions  to 

i'or  forty  years  Dr  IIoTme  filTedT/'  "'"'  ^^^^  ^^-'• 
of  Anatomy  at  Harvard  Tnitl.  ^°'*  "^  ^'™^'«««or 
he  was  able  to  cont  Se  to  hT^J'  '"'^  ^l''"  ^^^"^  ^hat 

and  art  of  medicine  in  the  md3?of  IT  °  ■'''^  "'«"- 
18  no  small  testimony  to  th«  v«      !-f-    "'^  '''^''^'•y  life 

which  has  placed  him  amon  JX  f '  °'  '^^  «^"'»« 
the  century.  ^  *^'^  foremost  writers  of 


I    j 


I 


10^-. 


* 


CLIN 


\fl    I 


i 


>,    \ 


Tvi'iirs  li 

liipsiii;;-  fever 

lever  lias  not 

many  years  ; 

iiig  yearly    1 

only  of"  the  ()1( 

in  lull  posses 

leges,  still  rei 

capacity,  to  ii 

r.irelessness,  ; 

kssional    sup 

the  autumnal 

the  latter  j)a 

be^'inniug-  of 

nervous  fe\-er  < 

scores  (jf  vict 

villages;  and  t 

of  the  century, 

the  year. 

No  disease 
and  thorougli  s 
tionsare  so  va 
experience  tiie 
')e  at  the  con 
«i'>(-'li  it  jjresen 

Pi'eliniinar\- 
with,  your  o'bs 
the  wards  I  woi 
important  liter; 
^^■hicli  v(Hi  wil 
the  library.  I. 
typhoid,  both  th 
'^t;"!i,  by  H.  J 
Wicles  in  the  . 


I-NTRODrCToKV   IiI-'\r\|.u-<  T        . 


CLINICAL  DKMONSTRATIONS   OX   TYP 


HOID   FEVER.    I 


J""ST-(;KA,n-.rKCorKSK,Jo„xsHo.K,NS 


HosP.TAr,,  OCTOHKR  ;„   ,sg.. 


/>>  //'//// 


«;w 


I!,.|,l 


'■'"■'"'■"^'■""'^'-^'  — ,.M..:,„.u..,„..,:vu..X,.. 


'''iilii'f  17,  |s(i|. 


l.^Ni  s  lever  has  almost  ^^one  ;  re- 
lapsing lever  we  never  see  now  :  vellow 
tever  has  not  reached  these  latitudes  for 
many  years  ;  niahuial  fevers  are  heco.n- 
ii.S  yearly  ess  frequent  ;  one  member 
o,.yottheohlgroupofthefeversre„,ains 

I"  tulIpossessKmofits  rights  and  privi- 
leges, still  remanis  a  witness  to  civic  in 

capacity,  to  municipal  folly,  to  domestic 
carelessness,  and  shall  I  not  add,  to  pro 


l^ssional    supineness  ?     Typhoid  "fbver" 

;-;'"t'nnnal  fever  of  the  Vhysicia,"; 

.clatter   part  of    the  last  ami  of  thl 

lii-MinuiK   of    this    centurv.     the   slow 

nervous  leverofHuxham.  still  numbers 
scores  of   victims  in   cities,  towns   and 

^  lages;  and  t.Klay.  as  at  the  beginnin 

;jti.ecentury,  it    is  the  serious  ^ve,;;]- 

Xo  disease  demands  a  m,n-e  careful 
and  thorough  study,  since  its  manirs! 
nuns  are  so   varied  and  the  larger  vour 

pen^ice  the  more  impressed  wiirv.;;^ 

'.icJ  it  presS'^"^^"    "^    "*^'-^-- 
Preliminary  to,   or  rather  concurrent 
Wli,  your  observation  of  the   cases 

theu^mls  r  would  urge  vou  to  read  the 
•■pc^tant   literature  on   the   sul^e'^ 

;Mi.x;i:.steifw;k^''" 

KM,  1 3    II.  J     i>,j^vditch  ;  (Gerhard's 
^^"c!es  1.1   the  .h.rnan,   /J.-.^/^;/,' 


between  tnl'   ^''^^'^■^^■'>tial   difference. 

dea  hud'  '"'•""   '•^■'^'"•'^^  '"^^■^^>-«  ^vere 
eU-s   w     i       ''r''^'-'  '-^"""""ced  ;   Bart^ 
lie    tu  wH™  ^"''"'■■'^   (r«42).  in  whici 
ere    an    thoT'fl-^'"'"   separately  con 

inrk   of  Murclnsoii    oi,    the  coiitimierl 
vors  ;  ,1,0  „,,icle  by  Lic-berme      ""I* 

'tiousuuderwhich  it  develops.     I  C 

'n,,.,-      1,1     •    '^V       \^itli   food  or  water 
n-e^  ,ettle  m  the  lymph  follicles  of  tlu 
estine,  ,n   the  mesenteric  ghSds 

stage  :^LZtL:Ti^,£^'^   '"'^' 
.-ving  and  extendi,^.  ;":,rS:^^' 


!      f 


ent  toxic  material  to  cause  symptoms. 
It  IS   important  to    hear  in    niiiul    tliat 
they  (1„  „„t  settle  on  the  mucosa  of  the 
I'owe     l,ut  tliat  they  grow   ///  its  tissue, 
an(l   tliey   are   not   iomid    in    tlie    feces 
ii'itil  the   middle  or  toward  the  end  of 
the  second   week.      It   is  an  infecti.m  of 
the  chyh>poictic  lymphatic   system,  not 
of    the    intestine    alone,    and    there  are 
tutal  cases  in  which  thelnnvel  lesion,  be- 
lieved to  he  cliaracteristic,  has  been  ex- 
tremely  slight  or  even  absent.     There 
may  he  the  most  inlen.se  toxic  and  ner- 
vous manitestations  with  very  .slinht  i-i- 
te.stinal  affection.  ^ 

The  dangers  of  the  di.sease   in   order 
of  severity  are  :   i.   The  general  toxemia. 
2.    Ihe  intestinal  lesion.    3.  The. second- 
ary infections.     The  typho-toxines  niav 
he  produced  in  such  quantity  as  rai)idlv 
to  overwhelm   the  system,  and  i,atient's 
may  succumi)  within  a  week  or  ten  days 
witli   inten.se  nervous  .symiitonis  before 
the   ulcers  form  in    the   intestines.     In 
other  instances  the  system  fails  gradu- 
ally in  a   less   profound    hut   more  i.ro- 
loiiged  toxemia. 

The  dangers  from  the  intestinal  lesion 
are  very  great.     As  the  necrotic   tissue 

separates,blood-ves.seIsmavbeenK!edaiid 
cause  a  iatal  hemorrhage  or  the  sloughs 
may  he  so  deep  as  to  extend  through 
the  entire  wall,  or  in  separating  leave 
so  thin  a  base  that  perforation  subse- 
quently occurs.  These  two  accidents 
together  account  for  fifty  per  cent,  of 
the  fatal  cases. 

Primarily  causing  an  afTection  of  the 
chylopoietic  lymph   glands  the  typhoid 
bacilli   may  themselves  pass  to  distant  or 
gans  and  excite  inflammations— nephri- 
tis,   meningitis,    pneumonia,    etc      but 
more  otteii  the  organs,  weakened  by  the 
prolonged  fever,  fall  a  prey  to  the  colon 
bacilli,   the  staphylococci,   the  strepto- 
cocci and  the  micrococcus  laiiceolatus 
which  cause  the  secondary  complications 
and    winch    constitute   the   third   great 
danger  in  the  disease. 

Upon  the  question  of  the  treatment  of 
typhoid  fever  the  profession  has  not 
reached  any  unanimity.  I  must  say 
that  the  cases  are  still,  as  a  rule,  over- 
dosed. I  am  sometimes  appal U-d  at  the 
number  and   variety  of  drugs  which  are 


P  Hired  into  an  unfortunate  victim  u,i|. 
tins    disease.      Vou  wili    here    luv, 

opportunity  of  .seeing  what  a  nonn  J 
c.nal  planot  treatment  can  do,  si,,', 
very  larg.  majority  of  our  cases  ,,.,viv 
"o  drug.s  from  the  beginning  i„  ' 
close.  VVe  employ  a  systeinaii;.  v,  , 
the  apy,  believing   that   on    this  ,,l, 

eer  am  percentage  of  the  cases  are  aul 
''»<!  ue  shall  continue  to  u.se  it  ,  ■  ' 
some  method  is  devised  by  wh  I,  u,' 
"•"■■t;>l'ty    in    large   series    orcsst 

liosp.ta,  practice  is  reduced  below  six 
seven  per  cent.  ' 

Not    much    progress  has    been   ,„-l 
;mh  the  so-called   specific  tic^u  ,.    i'S 

line  r'"'-      '?7'"^'-'''tn'l.<.idc„l,„,, 
have  been  used,  hut  the  number  of  CKs 
■s  as  yet  .scarcely  sufticient   uponwhid, 
o   base  any  positive  opinion      i   , 

durinrbHr'"':^^"*'^^'''---"-i;3 
culfurts.     Both    were     cases    ,,|    crrc-.t 
seventy,  and  one  patient  after  s.v.a  i, 
ections  seemed  so  ill  tliat  we  tl,o,J, 
't  better  to  abandon   the  injeciio„s  t 
returii  to  the  baths.      I„  thi  ^llC^ 
also  the  injections  did  not  seem  to  hJ 
any  special  influence.     Following,,  e^ 

l.einjectionsinha!fanhonrt],enatim 
liada  very  heavy  chill  '         ' 

agcd,  a.s  the  outlook  for  serum  theranv 
seems  at  present  unusuallv  bright.    S,  J- 
cific  medication    in   the  fever,  has  il.t 
kept   pace  with  the  enoinions  devflup. 
ment  in  our  knowledge  of  their  etiohxn 
JaKc,  for  example,  the  cases  adinitu;! 
during   the   past   two  daxs   which  v. 
saw  in  Ward   F  this  morning.     I„  hds 
.S  and  10  we  could  say  positixelv  that  hv 
specific  medication  the  fever  would  dis 
appearand  the  patients  would  he  afebrile 
at   the  time  of  the  next  ward  visit  on 
i-riday  ;  whereas  in  the  i)atieiits  in  beds 
23  and   24   by   no  method  of  j.n.mhire 
witJi  which  we  are  acquainted  an-'d  ue 
arrest  the  progress  of  the  fever.    It  i< 
however,  quite   possible  that  some  dav 
we  may  have  typhoid   fever  under  uiir 
control  just  as  we  have  malarial  fever. 

I  should  like  to  call  vour  attention  to 
the  fact  that  we  do  not  give  a  prelin.i- 
nary  calomel  purge,  nor  do  we  iiiiiui  if 
constipation     exists.      In    looking  over 


.1 


.my  Innjr  st-ries  of  oases  von    ,i.in   r    . 

arnk.  turn  tims.  with  diarrhea.  [, 
extrcmdy  nUc-resti,,^.  to  note  how  from 
t.m.to  tune  the  profession   return 

ol'H.as  on  praet.ee  which  it  had  aba 
'!'">"l  years  ap,.     At  present   v,n,  wi  1 

sjva,ooddeai,n  the  journals  about  he 
ehnnnat.ye  and  purgative  treatn.e  t  of 
'yi'lH.Kl  fever.  To  pn,„„.tc.  i„  ^,,^ 
way  the   exeret.on  of   the    toxines    ,  i    - 

m.!nMKM].esk,„aetiveandbvstimuat- 
inRtheflowot  urine)  is  a  mast  ration  1 

'"'^•''^'"■^'^esnnetbytl.euseofwat; 
eNtenial   and    internal.     If    the    b-  -ii  ; 
"-"'-tured   their  prisons  .il^he 
face  <.    ilie  mucosa,  calomel  laxatives  ■ind 
n.tesm,al    antiseptics    of    vario      "o    s 

;vouiabeu.d,cated.  butasf  menti  ncd 
"ymi,  the  universal  opinion  of  I  J 
cnolo-nsts  is  that  the  bacilli  are  ct 
'"•mcl  m  the  feces  or  on  tlie  muc4S 
•mt.  about  the  middle  of  the  seeo 
»x-ck,  by  which  time  in  .severe  cTsis 
•  i;'-«*'^"'Kl  toxemia  may  have  devek^e'l 

ami  ".anv  even  have  proved  fatal.     S 
or  in    the   disease,  when    the   slou<d  s 
have  separated  and  the  ulcers  are     rei 
e"t,  the  use  of  purgatives   is,    I  ]  o  ,  " 
very  bad  practice.  ' 

Tiic   statistical     details  of    the   cases 
jreated  ,n  the  hospital   durin,:  t'.e  firs 
l^.ur  years  you  wdl  find  in  the  Report    m 
T.v,.h(Hd  Pever  i.ssned  last  sprin^' 
)t.nn«the  fifth  year  of  the  irospifd 

"•<i"'K  May  15,  .894,  eightv  cases  wen; 
«t.d  to  a  termination,  of  which   f[^ 
1110(1,  a  mortality  of  6.2   Der  ee.>t  •  .1, 
t^tal  mortality  during   the   fc  ^V^';,!   : 
^iiiee  tne  introduction    of  the    Brand's 
nicthod  has  been   in  the  276  casJi    6  S 
I-rcent.      Of  the  fata!  cas^s  Sst ''eai^^ 
two  were   admitted  at   the  end    ot'  the 
ecoiKl  week  :  one  was  a  man  wi       e^ 
tensive  uberculosis  of  the  1  ^  rr.  h  Hands- 
one  .bed  of  perforation,     n.     "'asx'   'no' 
Posedtohave  meningitis,  ,s  of  ?Jceli' 
oiiahnterest,  as  it  ilhistrates  one  of  't    " 
commonest  mistaken  i,.  h,      i-  • 

typhoid  feve        Tl ',   ',  '  ">  ^''''^-?"°-^>-^  of 
J,-      ,  ^"*-  case  has  verv  ev 

;  |.l»nal  pthoIoKicil  fea.nrcs  am  win 
«  q.ort„l  ,„  full  b,  ,„,  i,|^.^„  .  I  '>  I 

S.VC  y„„  „  brie,   ab..,-ace  of  ?,. 


K   inouii.      J  he  ab(l(,men  was  a  littl' 
i  s  en  ,,,,        ,  ,,„  ,j,^.^.„  ^,^^^j^j    at, 

he  urine      s^" ''"•'"'.' •''•''^''-'■^'•'•^■tio^^ 

I'aths   and    SrecPc^   '/!''"  "I'°"^*' 
•11,, I     .  'i'<-ieo  a   cieasote   mixture 

;:-'  .morplua    hypodermically     iu^'Th, 

with   a  -,  L'v    .     •      ^^>^^'3es  open  an 

TM  arm     Were    actiT» 

to   be  livclv       ;,,f,>''^^-Jei'-^  appeare 
iuci\.       1  he  uterus  and    it«   nri 
uexa  were  normal.     There  was  a  smnlg 
amount  of  albumen   in  the     due    wit 
a  /ew  red  blood  cells  * 

of^tl/'""  '?^''  ^'''-^  '■isidity  ofthe  muscle 

was   noticed    thnt    tliere  wal    o '  !i     , 
swelliu"-    in    tl       ua-  ?    ^   '^''ff'i 

This  fel  f-^  ^f*    P'^^tid    region 

11ns  led  to  a  suspicion  ^,,1   the  pan  o 


1 


wiuAi 


l^r.    TliaycT    that     tli 

ii'igiit  really  lu'  I  vplioj,]  fever  "   I 

to  this  \vv  had  w^a 

of  iiioningitis.     The 


1 


oil 


bk 


lis  u-f  ha<I  R,irar(k-(1  tlie  case  as 


revioii.H      iial  c 


111(1    lioik-iuairow.      'J'hf  hra 


one 


'iHl  she  sank  and  died 


onutiii^  continued 


ord 
niv  (» 


liou  cd  no  c'lianut 
f  th 


Ml  an 


ol  May  I.     It 


on    tile 


for 


IS 


so-called   sporadic 
incninj,Mtis  are  instances  ot  this 
T'll!!!:      '"i'^.-^l'i"'"    type    of    typl.oi.l     f; 


i-'tre- 


nearly    five    da 


uitercNtinj.  to  note  that      which    the    1 


death    the   t 


ys    previous   to    her 


)ruiit    of    the    (lis 


e\rr, 


part  of  each    | 


eniperature   for    the  great 


er 


.lervous  systein. 


'J"l 


lulls 


99 


!>•  was  between  98°  and 


autopsv    showed     characterist 


ic 


The 
l^^onsof  t>,.hoid    lever,  witli"  ^;;^  mo;;      [I 
extensive   dr„ribut' 


aresonietinus  exirenielv  dinknil 
JH.gni/e,  but  it  is  well  f,')r  you  ahv;, 


I1-'     C'iiS 

t  ll 


le 


><-'ar   in   mind  Stok 


es  s   c 


ver    'there   is  ik 


lict 


uin, 


^inol 


re- 
^  ysto 
t'iat  ill 


bacill 


1   111   lii 


ion 

sjib't'ii, 


of   the    typhoid      indepciid 


in  wlucii   may  not  and 


IllIU 


ntl 


gie  nervous 
does  not 


v  ol 


:i(lnev: 


ol  the  inaii 


1,  nerves  ors 


any  appreciabj,. 


imial 


•'^  nip. 
Ivsiiiii 


lEOIC 


t33=B.f. 


JANUARY 


P 


CANr 


li 


Uv    1) 


fmi      Magazine. 

■    ■■■■  ^skx:  mmF 


fm- 


■'frtmn, 


Ci  uit 


■ts'a 


fe-^^^  -- J^^^Hiss:::; 


JANUARY,  1885 


CANr    ^  OF  THt   STOMACH  WliH  VERY  RAPID 

COURSE. 


Bv  WILLIAM  OSLER,  M.D., 

Pr.ronsor  of  Med.cin.    Joh„,  „„p„„.  Unive„ity. 


'   ) 


I 


■Hi' 


CAN-CiiR  o,.-  THrc  STOMAC,  W,T„  VUKV  ,<A,.,D  CO,r,<SK. 

HV    WlIJ.lAM    OSM'.K,    M   I)., 

IT..r.„or.,rM..,lic.i„e,J M  MupUin,  ,-,„v!.,i,v 

The  diagnosis  of  cancer  of  the  stonnd.  .n-.v  )     '  i 
causes,  an.ong  which  perhaps  the  I  ^st  f.         '     '      ''"""'  ''>'  '"^"> 
duration  cf  the  disease      Thl    u  '     '"  ''"'"  ^''"•i*'' "">••'*  i"  the 

ti>ree  years;    a  dur::  ^n    ■^J'72^'''''^'^  "'"-  ^'>-  ^wo  or 

while  a  rapid  course-three  n  li  JTst' V""'  ^''"''''"""' 

evun  in  younir  persons   in  wJu.,,.         .T  ''tiU  tnore  uncommon, 

0,..,  ..e  „„„4L  or;:.;'!'::;::",:,,:;-:;- «.-"'  '"■  ^^■^■'="'  "•""•» 

weeks.    With  theexcentonnf        ^^"     T''  '^'^  ^""^  ^^«  ""^er  six 

enjoyed  good  hLX'^r  hLT-^:;;:  /''""'^  ^^!'^^^'-^  '■^'  ^-'  •"'->•« 

At  the  post-morten,  there  was  found  a  S^'  7"'  """""'^  ^■°'"'^'"^- 

prese,,.  .ve  J  reau^' ^?  spedlire;/,"™'"'  '  ''■'"^^-     ^■"'  -- 
rJl'tZ":""'  ""■='  °'  '^"■■'^'"^  ™'*"  "^  "■=  oorrecion  of 

s.o.«hLrof  r  l::;''''^"''^  °*-""-^  (»-»'  f-^O  °0or,  d„e  .„ 

m,b,-  Diffuse /„T'r,LT     ■^''"t"""  «"■'  «'»«    ■■^■UM„    T-.,, 
trouble.  "•""  "^P"' "•  ~°'P'a">'"S  of  vertigo  and  of  stomach 

'  Johns  Hopkius  Hospital  Bulleti.i,  Vol.  „. 


!    1 


IVilliavi  Osier. 

good"'"  He' W  V  '  ''"■'^^■'r '^^'-  '^y  o-upatiou.     His  habits  have  bee,, 
good^^    He  has  been  a  steady  smoker  in,til  about  a  month  ago 

The  patient  was  well  and  strong  as  a  young  man,  and  has  throu,!, 
out  hfe  enjoyed  tolerably  good  health,  though  for  many  years  let  ' 

months.     Iwo   years  ago  he   had   an  attack  of  biliary  colic   sev. 
enough  to  require  hypodermic  injections  of  morphi      Vou    mo  tl  ! 

A  terThf^th      r'  '  "'°"'  ^''""'^^  ^^-'^^  S-^^  P^«  -  the Tgir     r 
After   his   he  skin  was  a  little  yellow.     He  has  had  no  attacks  s„cf 

a  s.milar  character.     For  about  eighteen  months  he  has  had  attack 

severe  vertigo  associated  with  flatulency.    The  first  one  occurr  u  .v,  i 

he  was  sitt,ng  at  the  table  in  a  restaurant  drinking  claret  pui  oh 

jumped  up  and  said  to  his  wife.  "Catch  me  catch  me  "  n  ,H       J  '. 

hold  of  ,,    table  to  steady  himself.    He  hfd  alt^n    ^  f  tt  2r 

attctts  eTib"  T  T''  ^°'  ^'  ''  ^^'^^^"""^  --  '"  motion 
a  tack  la  ted  about  an  hour.     He  did  not  vomit,  but  looked  pale   -ut^ 
broke  out  into  a  profuse  perspiration.     He  has  had  only  two  attack- 
similar  severity,  one  while  in  his  carriage.     He  said      Limed  ;: 
horse  was^down  and  everything  was  turning  over.     This  at  ack  1       ' 
about  an  hour.     He  had  to  go  to  bed  and  felt  very  badly   "nd  a  , 
he  was  all  confused  in  his  head.                                          ^'          ^^^'''  '' 
The  milder  attacks  have  occurred  with  great  frequency      Scircelv 
a  day  passes  without  one  or  two  ;  thus,  yesterday  after  breakfa        ' 

whatever  in  the  chest  or  elsewhere.     The  attacks  do  not  come' 
during  sleep,  but  he  has  had  several  of  them  while  in  bed 

^roni  his  statement  the  vertigo  apparently  is  both  subjective  -.nd 
objective.  Objects  go  to  the  right,  but  he  feels  that  he  u  ,  V  "^ 
In  the  attacks  it  is  impossible  for  him  to  walk.  It  appears  to  1 '  i 
one  foot  goes  about  ten  feet  higher  than  th.  othe       K  h    lea  M 

tight  the  attacks  do  not  appear  to  be  so  severe.     He  ha    never  o      1 

IS  t^rweek.r  '       '"'"^"'  '^  '"  ''''  ''''''  ^'^'-"^  -»  ^^ 'ck 

He  lays  the  greatest  stress  upon  the  condition  of  the  stoniach  i,,,! 
says  that  everything  comes  from  it.  and  that  the  belching         t:. 
and  most  distressing.  ^       nK-t.vsaiu 

Though  he  did  not  complain  of  difficult  hearing,  it  was  evident 


Canrcr  of  ,ke  S,o,..„,,  „,„,   ,.„-,,  ^,^,y  Co,..se.  3 

in  which  ...ere  I,    i'^i  Ho   e  n^lT''  """■"'""*■ ""  ""^  "«'>'  "'• 
-cl.  louder,  a„d  so^Se"  t  ere       h   r";""""';     '"  '"'  •■"'^"■'  "  - 

special  scleroMfof  ,  farteri  ,  '1'    7"' ■     ■""  """-^ '''  '''•■     ^o 
N-o  increase  i„  area  ..fX,,!  Thrs^  ™    ■;lT"'"--'  ""'  '^'■■'=^'=- 

.acce„tuated  at  the  base.  TI.ere  is  a  sT.!l  r  '"  ""^  """'"^  ""^ 
area.  Nodiastollc  m„r„,„r  a  ul  We  '°!J,-J!°"=  ">""■""■  >t  the  aortic 
icnderne,,.,  on  palpatio,,  at  c„  a  arBil  T  '"  I'  "'"  J-'^S'"-  No 
.h-nded.  T.n,pa„,.  extends  o.f,  ril  0  1^,1 "  '"t'T' 
al)Ove  the  navel.  Soleen  not  n.i„  ,  1  "'  ""  '°  'hre^  finger-breadths 
ri.ht  side.  He  sa,f  ^  Li  £  I,  ^^l^  ^^^  ^^P^i-d  on 
years  He  can  hear  the  watch  i„  do  ontac  ^^tlTTr '  ''"'' 
hear  It  at  a  distance  of  six  inches.  ^^^^  ^^^  ^*" 

Dr.  Theobald,  to  whom  I  referred  the  mti^nf  r 
■he  ears,  wrote  .bat  tb.re  was  deafne^  ,'r,„''e°   !  ^  :;X";""T°"  °' 
ni  the  and  torv  nerve  or  it«  «„,..     •       •      ,  ^  '  ""^  *°  changed 

was  a.so  slight  ^z  •  tiT  e^rriv"  ?,:jf -■■■'^'^-  .-^ "-  ^^- 

showed  a  rather  high  grade  of  1 !  n         .  examination  of  the  eyes 

of  ascigniatism,  whi  hTe  tilt  t  w""rr'  "'''  '^  '^^^~''^^'  ^^^^ ^ 
Rlas.ses,  as  the  error  of  rcfr't  '  materially  benefited  by 

-'  i"g  the  atti:;::^  t^^^'^,::r^'  ^"  ^^^-^-^  ^--  ^» 

was  reasonable  to  suppose  t   at  th.  ,     '  '^''  "'''^^  ^"^'^  '^'^'  it 

with  it.     The  chanee^n  tl  !  ''  '.  "  '"'^'^'  ''^^^  something  to  do 

i-d ..as«es:::rstr::rr: r  u::^.^:^^-  ^^■'-''-^^- 

the  end  of  May,  and  said  tl,«f  J..  "e  came  to  see  me  again  towards 

■•ad  l.e  had  no  seve  e  at  tcl   ^,7^  T7  ^  •""  '"'^  =  '''''  ""^  °"'y 
peared  completely      His  Ton'  If  ''"  """^'"  ^"^'^^^  ^^^  disap- 

not  nearly  as  bad'as  it  iLte;::  '  ^""'^^'  '^''"-  ^"^  "^  -''^  -s 

His  «"::"irt::;^t:^^/""^  ^^^t'^  "^-  ^-^'--^• 

kept  abont  and  h,ul  been  tran^"c1in  V''  ^"'^''  ''^""^'^   '^^  ''=^^ 

".    On  that  day  he  beln  to"  v   t  ^-?^.''"-"ess  as  usual  until  June 

thing  on  the  stomach  s.eetheVr";"^'  "f  '""''  "°^  ^^^'^*"  '''">'- 
tl.i"R  into  his  stomach  wi  o  .t  ag  ravath'  "h'  ""  '"^  ^°  ^'^'^  '''">^- 
tervals  between  the  attackrl         .         f     ^^  ^'"""ting.     In  the  in- 

distress  is  just  pri:rr:i        :    ng  t^tta^^.^'^rr^"'  '^'  '''  ^"'^ 

or  four  hours.     The  material   '"f  "'7"^^'^^' '  ^^'^l"-ec»t  every  three 

cole,  and  not  bloody.  "''"'  ^'^  ^^   «^^^  ^^t-r>'.  grayish  i„ 

To-day  when  I  saw  him  his  condition  was  as  follows  :  He  looked 


H 


^  Wa/iam  Osier. 

slifih.  fur.     H.  bdche.,  a    „  er  T    Tl  1,,"  '"",  "' '"°''"'  "■"■  '■'"  " 

Of...  s.o„.ac„ ;  .he,tTare'r„.,;::';;;;^,:r  '= '-''  '■■ "-  -™ 

I  tl,„ugl„  fr„„,  ,|,e  ac,„e  on«t  a„d  severity  that  it  might  nossihi. 

er;rx--;i:;i:--r-:;-:5 

On  Monday  and  Tuesday  the       miting  continued   and  h. 

.hi,,  ,e*„,,h-bro„.„  fl„i;,,  witf :x;  , :  eXe,;' '°  T^'  T- ' 

s,.ch  Iha.  we  suspected  perft.ratic,  i,,.o  ,l,e  bowe         t  wn!           ,' Tf 
l,ow  ,„„oh  I,e  brought  up  fr„,„  the  s.,„„      .  in  tt  tw  rfr"," '' 

,:L':;::u:eh."""'^'  '■" "" — "- = --^  "^  --  .-"n^..'.,:,,':: 

The  examination  of  the  fluid  slmw^d  f),nf  ;,■ 
feebly  ^r  free  „ydroe„,„,ie  aeid.  ^Iti::    re  "  ^."^^p::;.^^'' 
ular  ./,V;/v>,  hut  no  formed  elements      On  1'     T      ''°'^"''^''-''  -'^■'"- 
e.a„.i„ed  the  „.ateria,  w..,d.  Z ' bee.f  J,  :?::  s™' ','.'^,  "',r"" 
eJit-eraely  foul,   wi.l,  a  dis.ir.ctly  fecal  odor      LI         V  ""' 

was  fouud  i„  ,he  f.ag,„e,..s  of  blo'o^clLt  u  ,^^Z:r'7'::^ 
mouas  was  seen.  The  pipette  wltieh  I  used  ,„  re„,„v  .  stuZ 
been  standing   n  a  iarof  witer   h„f  t  i    a  ^  ""vt  me  nuui  Had 

draw,,  alcohol  into  hbifJe  '"iug  "  "  --"-'"ary  ,„.„„ne, 

n  ucn  the  sa,ue.  hut  he  beca.ne  weaker  after  each  vomiting  spell     i„ 
tl.e  even.ng  ,t  was  evident  that  he  was  failing  very  r„p,>, ,y  ,!!„,  I 


ifi'';ii[innif f ~ fr  i iiiiirn-  ':   -i 


Cancer  of  ike  Slo.nacl,  e.M  :.,,,  f,,^;,  Course. 


He  sank  and   died  en  the  morning  of 


had  not  the  strengtii  to  vomit 
the  5th. 

nnterior  „.„  were  .lo^e  'u^L't;'™;":  ■,""''  ^  "",""  """' "  "^  "^ 
tlie  left  lobe  of  tlic  liver      n„  1  f,^      .,  '''^     S»"  '«"■«  co%ered  by 

.he  .ra„,ver»e  „,'„„  „.!  a,y  Jn  of    £  '''°'','- V"«'^"ecl.     Neither 

c.vity,„,tbesa,n,l„«„e„:ltl  e  ri/n"""  "'°°^  ""'"  '"  "" 
tl.e  organ  was  tbe  .eat  of  a  dim"  m  ated  ™""'"'-  '''"=  """^  "f 
curvature  and  tbe  posterior  wa    I  7  •-•.■"rcnonta.     In  tbe  lesser 

of  .be  band  slongbinj  "d  .Ik'n  "l  "  ""t,'''"'-'  ""  "''  "'  '""  '"'" 
ated  snrface  to  whicb  shre  s  of  '  oroticTitrw  " '",f '  ""••  "'"^■ 
index  Bnger  conld  be  oassed  i„f„   I  ""  »""'"™..     Tie 

was  free."  Tbere  was "oTerf"  "i  n'  '■^'°",^. -■««  ■  '"^  "«"-  orifice 
were  no  cbanges  in  .be  ot'b^bdo.nit.aTXr  "'°'  ^'"°°"''  '"'  '""^ 

.r„w°:r.r;s;o,r:rb'ad'trof  r'  t  ;;  ^-^^^'^ "'»'" '-»'  '^^ 
no.  -io,,siy„„dernH,.'di,iT,,r„r;  ;■■:,',  'Tz "" "  ■■^■' 

to  have  seen  such  a  remarknhl.  .^  ■'^'^^"Sth.     I  rarely  remember 

...e  .orrection  of  bis  ::::::^£;::^';^-  ^:;r  '^t  ""- "'- 

1.,  he  was  "  living  a  new  life  "  ,nH  L       r  "™''f' ''■    ^'  '^'  expressed 

of  May  he  looked\erv!n„  Ibelter  Tbed  ""  "■'"  '""""^  ""  "" 
bn.  be  no  longer  had  ,be  i„C„.  mI^^'^Z:"^  "-™"  '"-• 
ser.ons  a.,d  fata,  illness  was  wi.hin  a  .nt,.  o'f  ,h  s  d  «  "This"  "^ 
of  n.fil.ra.mg  neoplasm  disturbs  in  tbe  le„t  d.„  L  ,i      ,  ™ 

.he  stomach,  and    tbere  are  n,,,  .  *    "^  ""^  functions  of 

had  dim,se  carei„o„,rwl     e  tirrni;:/"-"'  "■""   ""■= 

good  almost  to  the  end.  '"lP«>'le  and  digestion  have  remained 

c.se,?m;;tbe';7t'h«"V'"K"''','"''  '"'  '■°"-'"'  ^'-^■'  ■■"  t>- 
a  fe^al  odor  oftl  vo,^  tns  S/'le  1  """""''  """  """  "-  ^1- 
howe,  as  well.  Very"  rs'ibW  1.  'L  "i  ^-^^^l.rr-"'™  "'"- 
™-.g  ...ere  was  ntore  or  less  regnrg'i tat'  Ir^'f  t  iZel'^r 

-eiief'tfThrrrf;;:,^:  i:;"S. '™"'-  '■■  -^^  --  --  «.^ =....« 


^ 


T 


'^  L-l'li 


TEACHING  AND  THINKING 

The  Two  Functions  of  a  Medical  School. 


BY 


«'M.  Osmu.  M.1,.,  KB,,,,, 


more. 


i 


...■.^ 

^-xi 

'.-,,_.„■„.,. 

-■ 

^^■1 

1 

1 

1 

H 

V 

1 

Rrpnnt.l  fn,.„  ikr   M,nU,;.a  M„lir„/  Journal,  F.'hrnnr,  180.5. 


TKA(MII\(;  AM)   TIlfXKIX 


Till-:  T\\(i  l'"i\(T(o.\ 


"^  OF  A    Mkdku,  S 


Many    tliiiins   hu\-,,   i 


I'lllMII 


M'i'll     illi;'( 


'•'■iitury    civilization^tliiit    political  ..r.frand.i 


1,1^-aiiist   our  iiiiictrcut 


nils  III   {luarcliv,  that   tin 


SClllCllt 


(>n!v 


I 

Iv 


wiilcsia'cad   unrest  i 


I'iiituul  Irakis  ,mly  to  UMl„.|i,.r,  mi,|  that  thr  hrst 


taiy  on  our  Itoastcd  culii'lit 


aiiMsand  the  nat 


fnnicnt  is  tl 


Ofth 


ionsc\ciy\vii,.i'c  "iiai'i'i 


n  iiiattci-s 
coinnicn- 

•'   l>i<'tuiC  of  Imij',,|„. 


tilrf 


I>i'a('tical  })L-(jMiv.ss  in  on,'  diivct 


u<y  at  each  ot 


i(  rs 


(■an  lie  no  doulit : 


ion,  h()\vt'\ 


rr 


no  on 


can  (lis 


moils  iiicivase  ni  the  conifort  (.f  each 


|iiit( 


viz.,   tJK' 


t'lior- 


I'ftiwly  tlic  huinai 


iii(li\  idiial  life.      ( 


1  nice,  or  portions  of  it  at  any  rat 


an 


liavc  in  the  pastcnjoyc.l  periods  of  ureat 
intervals  of  freedom  from  strife  and 
lias  iievi'r  heen  wlien  tl 
til''  man,  and  the  man  aloii 
"li'ii    th.'    individual 


C,  111; 


er  repose,  and  lon»-ei> 
xiety  :   l.nt  the  .|; 


so  sacri 


win '11     tl 


"Hit  has  lieeii  of  such  valu 
lasheen  so  much  the  i 
livinn-  oru-anisni    lia 


'.V 
<\  when 


ueasui'e 


as    a 


s   seemed 


II'    olihu'atioiis  t 


scfliied  so  nil 


pcr«tivc.      |!ut  tl 


c< 


)iHparisoii    M-ith   ti 


H'Se  Cham 


Dei 


"K-     Thehitt 


ic   renicrkahle  inc 


"  ivirard  his  rights  hav( 


;i's  are  as  nautjlit  in 


rease   ni  his  physic; 


Ciition  of  the  nat 


or  cry  of  Isaiah  that  with  themultii>l 


ions  their  joys  had  not  1 


lioiiiiirks 


iiiiidn  lit  th 


pll- 

>oen  incieased,  still 


f  "pening 


'"""-  llopkius  University,  Bolti 


th 


^e.  by  William  oX"y:i,  ,"F.f  ^  i 


F  k^P  p""!^'"''.  "'„"'«  Medical  F«c.ri 


more. 


toiij.,  Protossor  of  MeU 


auulty 
icinc 


► 


I      i 


I  i 


' 


I 


•  ■f'lioi'.s  ill  oiu-  fiirs.     Th 


ti'Uf,  iiKiv  not  liiivc  li 


|Wllll 


IIIKl 


suf] 


•  ■niiL''. 


tl 


1'  sorrows  jiiid  troul.Irs  of 
■'■"  iimt.M-iully  <liini)iisli,,|,   l,ut  l,o,| 


iiirn,  it  is 


lOI 


i.^li    not   iilioli.sli,.,!    liavf   I 


ilv 


simnv,!   as   never    hcfor,.,    and    th..   sluviv    of   <,acl 


We/lsr/, 


'niwrz  lias  l)c,.n  ciK.rniouslv  Ifsscncd. 


)wii  as- 
1    in    tlif 


Sorrows  and   t;rictV 


to  join  us  on  our  ])il<.Tiiiiauv,  and  wv  I 
■•■sensitive  to  them,  and  p.^ihaps  I 


are  (•oiiipaiiionssiire  sooner  ,„■   | 


ater 


lave 


IIIOI 


'eeoiiie 


<«ld  time  reme<h"es  of   the   physieiaiis    of   t 


jK'rhaji 
t'ss   :imenalilo  to  thi 


ixillis  and  woes  of  tile  hody,  to   which    we  .|oet 


soul  :  I  ait  til 


are  deereasiiii^-  at  an  extraordi 


oi's  ministi 


nary  rate 


makes  one 


In    h 


nirly  yasp  in  hopeful  aiiticipat 


iiid  in  a  wav  tl 


lilt 


iiai. 


lis   <i rminiKi r  nf  Asscnl 


siifreiiiin-,  ,|,,hii  Ifeiirv  \ 


in   a    notal 


fwman  asl 


measure  tli 


aenfcoate   of    J 


"s  endured,  and  will  endure  f 


iini   winch   this  on 


W 

th 


passaire 


lo  can  wei< 


on 
ami 


w  n'eiierarinii 


add  to  thi> 


th 


loin  liirth   to  death  :'     T 


our  race  tlirou<,di  centui 


pnin  which  has  fallen  and  will  fall  u| 


II  in 


the  other 


ics  past   and    to   eoi 


ta 


aiiti' 


view  of  it— think  of  the  N 


liut  t 


like 


ken  pain  .lurin-  the  past  fifty  year 


einesiswliich  I 


las  o\i'i' 


•ejitic  siiie-ery   have  almost 


■s!     Ana-sthet 


les  a  I 


1(1 


since  their  introduction  th 


manacled  the  d 


eliioii.  iuii 


•n  prevented  far  (aitweiVhs  in  civilized 


ignTojrate  of  pain   wliici 


I   liii^ 


^vhicll   has    lieen  suffered.      K 
■n  lifted  from  the  soul  of 


v«'n  the  cui 


communities  tluit 
se  of   travail  ha-- 


Tl 


w 


n. 


e  <,'reatest  art  is  in  th 


say  that  we  of  the  me.lical 
Vou  of  the  puhlic  who  h 


aiiaii 
concealment  of  art,  and  I 


n'ofi 


iiiii\- 


'ssion  excel  in  tl 


lis  respecl 


ar  me  oo  ahout  the  duties  of 


ay   profoundly   indifferent   to   the  facts  1  I 


tioned.     Y,,n  ,] 


for  t 


not  know,  many  of  you  do  not 


le  crossdeei,^..!  .luiio  who  presided 


lave  just  iiii'ii- 
care,  that 


your  ,i,n'andparent,s,  tl 


lei 


leife'ec 


over  the  arri 
■e  now   sits  a  lienio-n  and  str 


.i,^o.Ides,s.     Yon  take  it  for  ..ranted  that  if  a  si 


iiiilit 


IS  dislocated  thei 
in.stead  of  the 


is   chloroform  and  a  del 


mnl'ler 


fifty 
if  ^ 


years  aifo.      \ 


aji'ony  of  the  jiulleys  and 


icious   Xepeli 

parapln  riiali 


I    et 


accept  with  a  selfish  complaeeinv  a« 
jou  were  yourselves  to  he  thanked  tor  it,  that  tl 


le  aiiuw.' 


,'r:icy,  ii>s 
[■  aiTuws 


)t'  ilcstnietioii   ll\-   i„,t, 
•I 


tliiekl 


n..\v    raivly    walkctJi    in    the    ,|u|.|, 
nalizc   that  yon 
with  )i   I't.'iisoiialil 


y,  and   Mint  tl 


K I  less 


may   \u,w    pray   llic  pr 
I't'ospcc't  of  its  i'lilHliincnt 


II'  |M'>til(.nc(' 

'y'i',,r  iirzckiiii, 


.science  has  made  to  almost  evecvol 
a  few  years. 

I  .say  you  i| t  know  tj 


■since    III 


le  o!    voli  tl 


oilei'li 
pi'eselil     1,1' 


ami  the  more  intelligent 
ill  yoiir  lieai'ts,  Imt  tlie\- 
take  foi'irnvnted,  like  tlie 


thill 


^'oi,  I 


:iiiioiiy  yon  pi'ihaj) 
ai'i'  aiiioiiu-  th,.   thim 


em, 


le.ir  (if  th 


|i"llilel'     til,. II 


which 


Di'ioiLs  lioavcns. 


suiishiiic,  mikI  the  II 


on 


"\\l'l'S,  illld  th, 


tl 


"I'is  no  idle  cliallcnu'e  which  we 
le  world  when  we  claim  that  (ai 


I'li.Wsieiaiis  tl 


'W    out    tl 


am 


1  of  th 


noblest  kind,  not  n\ 


r  mission  is  ,,1'  tin    I 


liicatiiie'  til 


people  in  tl 


"He  in  ciiriiiL!'  d 


i.si'a.'- 


IllL 


!'■  I'lws  of  health,  and 


IlLI'llest 
l.llt 


III 


the  spivad   of  plaeiu'.s  and   la.stil 


111    pre\(.|| 


i^aiii.said  that  of  late  v 


leilces  :    iinr   c-m    it    I, 


ears  (air  record  a- 


a 


mure  encoura;,nn-'  in  its  practical  results  tl 


Dtlier  learned    prof 


iMKJy 

mil  t 


leen 


lim- 


hcst  ideals,  tar  from  it 


ssions.      Not  that 


lose  ol 


we  a  I 


liicli 


Ideals,  w 


ueans  more. 


we  are  laily  men.      Hut 


live  up  to  the 


We 


means  much,  an.l  the\- 


lia\-e 


Of 


.■r»'e  for  .shekels,  wl 


course   there  are  ( 


I'c   realizahle,  wliieh 


i.veii  and  tlie  jinolinir  of  t| 


lose   ears   hear  oulv  th 


'I'liazis  aiiionn'  u 


■s   Wllo 


tioi 


IS,  am, 


th 


le  j^'uiueas,  i.ut  tl 


lowini;'  of  th 


le.sc 


ami 


e  rank  and  fil,.  |; 


are  e\ci 


sclt-.sacriHcini--  devotion  t 


il'our  earnestly  for  voi 


II'  Lfood. 


hcst  Work 


'  your  interests  animat 


I's  our 


le  e.xerci.ses  in  which  wi 


are 


'"cident    in    this    heneticent    work 


cvervwl 


icre:  an   nicident   whiel 


<>-day  enya^vd   f 
vvliich    is    in 


1    wil 


II 


pun  certain  as])eets  of  tl 


enalije    111,. 


preinotion  of  tile  physical  well- 


ic   university  as  a  fact( 


orm  an 

proLfros 
l:i  dwell 
r   in   the 


great  university  has  a  dual  functii 


•me-  of  the  r 


ice 


tliiiik.      The    educational 
I'lii'i'ijies,  and  in  th 


iiiKi  in 


I'll  Hi  I 


>ii,   to  te, 


ich   and   t( 


aspects   at   tirst    ahsorl 


rii    a! 


c  eijuipnient  of   the  va 
providing  salaries,  it  finds  itself  I 


Its 


c\en  the  first  of  these  d 


uti 


nous   li'partmeiits 
pressi'd   to 


iai  .| 


OS.     The   ])e,-i  has  told 


us 


I  i 


6 

"    tl"'    Inst    .•■■mk    as  a  Iraclii,,-  l,n,|v       |  I,,,,,,,,  .1,.  , 

^:?':;M:S-;;:7'-,i;:;:t-{:i5-?^^ 

ncr,        l,.,tl,  ..     whu-h    ,nst,t,Uio„s    lonn   .nosfc  ...ssnu^   I 

Hlml,  . natter,  an.l.t  is  for  tins  that  HV  ask   th.    ,1,1   n,. 

""-•     (''•■•"■^t'y,anat.Mnyan,l,.|.vsiolo,v   ,nv,.  th.t    n 
;;i-tn..,,ie,,..na.,,..s,,n,t..p,ao..n.;;a;;,n!l 
tl...p,.op...p     iUo,.intlH.solu.n...oriitV,an,lafi;,nh,, 

tnrstuo.tl.y  ,.x|H.m.ncv  ..ay  1...  la.ilt,      Ka,-!,  ,.n,.  „r  ,1 i. 

-■nc..   ,n   ,ts.  r,   ..,,,,,,,,  „.,,    ,„„.,„    ,,,. ,,,; 

ate    tlupnnc.pl,.san,le..rtain..n  ,  „,,, 

•       ....     ,>„n.l..,,.     Only  s,.   fa.,  as  tln.v  l„.ar   ,p„n  ,.,  ,h„. 

t     .,nv.partoitln.u,c.,la.alcun-icu!„n,a„,lf,.,.„stl,,..,n. 

c.    not    .ec..>n.e  a  cun,pet..nt  surgeon  without  a  full  k,..wl- 

..- o  hmnan  anat.any  an.i  physi,,l..,y,  a,,,,  ti,,.  phvsi..,.,, 
-t Out  pl^.s,olo^y  an.l  ch..nusto-  Houn,h.rs  alol.,  i.  .. 
a"nles«  lasluou,  uc-ver  able  to  gain  any  accurate  cone,,,.,,,,, 


I' 'lisfiisc.  pnictisiii"'  II  sort  ,,!'  [„,i 
nnw  till'  iiialii.ly  mid  nyain  tJic 
kim\\'iiii;'  wliicli. 

Tlic  iii'iiiiary  fiiiictioii  ,,{'  (his  ,\, 


';,'•" I   plmnimry,   I,it,HiiM 
I»ifi«'Mt,   lie   Iiiins..|r    not 


>tty   IS   to    tfiu'li  iitcii  (|j 


•|>'irtiiic'iit  ..!'  tl 


^'•'is.',  what  it  is,  its 


iMT' 


ow  it  limy  l.(.  pivvciitc.l,  ,ui.i  how  it 
■  liii  these  thiiiHs  the  four  hull. In, I 


iiiaiiit'esuitioiis, 
'"■cnivd;  and  Ut 


i.'iesi'  lieiiclies  lia\ 


Is  nil  11 


eht 


<•  collie  IViilii 


IIKIV 


,V""II^'  men   Wlin  sit 


on 


iiin 


ill 
till 


tter. 
tliciilties,  s( 


ivsponsiiiility  which  a  facult 


|'"its  of  the  land,      liiitit 


task 


IS  not  eas\-   I 


leuiii' 


>nie  inherent  in  tl 


,v  fissuiiies   in   this 
■•■^ct  with   countless 


Mien    thelliselv 


"'  snl.|ect,  others  inf 


iiiltiti 


Kle 


T 


■'•^  "nd    nut   a  few    hniind 
"""'",1;  which  we  do(.t. 


dent  in 


lip  with  th 


le  processes  of  disease  ai 


M\ely  ditKcult  t( 
ami  aithouiiii  we  1 


searcl 


ors  Work 


■''  ^0  complex  that  it 


I  o'lt  the  laws  wliii-h 


is   e\ 


"^^■*'    ■^'''■"    'I   t' plet.'    revolul 


control  tl 


Ces- 
lem. 


ideas,  what  has   iH-ei,   accoiiipjished    1 


1011    III  our 


iiii'i 


iicinc  is  oidv  an  ea 


ic   three    OTcat   adv 


nicst  of  what  the  fntu 


'V    the  new  school    of 


i'<'  lilts  in  stoi 


kimw  lei  L''e 


)f  tl 


"I'c^'s    .)f    the   centurv    haw    I 


the  iiitrodiictioii  of 


ic   mode  of  controll 


leeii   a 


htic  method 


iiavsthetics,  and   the  ad 


1"^^  epidemic  diseases 


■s  111  surirery.      Heside  tli 


nisipiilicauce,  as  these  tlin 

l»Tsn|ial 
causes  o 


the  discovery  of  the  methods  for  tl 
Mich  a  sfoiirj-'e  as  typhoid  fever 


contril.utc  so  01101 


option  of  anti- 
cm  all  others  sink  into 


comloit  of    th,.    individual.       The    study 
t  so-called  infecti.ais  disordiTs   has   led 


■monslv  to  the 


of    tl 


le 


directly  to 


ill 


presence  of  perfect  draiiiaire  and 


nater   supply.      The   taitlook,  too    f 


icirccaitrol;  for  example, 

lecoiiies  almost   unknown' 

111!  uiicontaminated 


tieatiiient  in   tl 


lese  a 


tfect 


I!'  specific   methods  of 


lulls 


't   not    lie    disc( 


■•'IIS  IS  most 


mraired 


laillll'es. 
are  mi  tlu 


tl 


In' 


few, 


I'opeful.      The  puhlie 
or  even   by   many 


linkers   who  ai'e  d(.i„fr  tlio  work  for 


ri.i^ht  path,  and  it 


voii 


IS   HO  vain  fancy  that   l.ef 


IIh' twentieth  century  is  very  old   the 

t  many  of  the  conta<ri,,„,s  di.seiso.s. 


ore 


\acciiirs  ae- 


uns 


re  may   he  effective 


■'lit  a  shrewd  old  fell 


I  CS,   111(1 


any  di,seases  are  less  f 


"W  remarked  to  me  the  other  d 


requent,  others  have  di; 


ittp- 


'■' 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


% 


A 


{■/ 


^.% 


<? 


t>    4 


.^^  Jr>^  .  -m^ 


i< 


m 


7i 


1.0 


I.I 


■-  IIIIM 

■  5  0     ""'== 


L25  III  1.4 


IM 
[2.2 

IIM 

1.6 


if 


i 


e 

c 


V] 


^» 


^ 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  NY.  14580 

(716)  872-4503 


-^•V 


iV 


■O' 


\ 


'€^ 


%^  ..*.  ^ 


( 


:  I 


^ 


pi'«ro(l,  unt  iK'w  ones  arc  always  cr 


ays  cr<)ppinf:f  up,  and  I  iiotic, 


that  witli  it  all  tliciv   is  not   only   no  decicasf 
yivat  increase  in  the  lumilicr  of  (joctoi-: 
Tlic  total    aholitioii   of  the    infect 


hut 


a  V 


expect,    and    for   nianv   vears   t« 


iou,s  o;r(Mip  we  eaiiiidt 
<>   eoiuc   there  will    iriuain 


is,  even  aiiioni-'  preventaiile  nialadit 


t( 


hosts   of  liodi'v    il 

occupy  our  lahours  ;  hut  thei'e  are  t 

jiiain   thi"    relative   nuuiorical    increase  in  the  profession   in 


wo  reasons  whici 


1   e.\- 


)it( 


)f    tl 


n.'at    decrease    in    th 


number 


)f 


certiiin 
Il   I'lii- 


•  iiseases.     The    development  of  specialties   has  oi\-,. 
Dloyment  to   many  extra  men   who  now  do  much  of  th 

ioner,  and  anain  pe()|)lc  cni- 
fj^ive  occupation   to 


work  of  the  old  family  practit 
ploy  doctors  more   fVcquently    and 
iiany  moic  than  ff)riiierlv 


It  cainiot  l)e  dein'ed  that  we  have    l<'arned 


how   to  ja-event  than    1 
definite  outline  of 


moi'e   rapidl\ 


low   to  cure    diseases,   hiit    wit 


J    ;i 


our  lyiiorance  we  no  lonj^er  live  i 


a  fool's   i'aradise,  and    fondly  ima^i-ine  that  in  all 
control   the   issues   of   life   and    death 
potions.      It  took  the  pi'ofessii 


low    in 


1    with  our 


cases  \\( 
pills  am 


that  fevers  ran  their  cou 

hy  druos,  ,u,d  the  tOO  which    old   ]> 

spent    in   medici'ie   in 


>i.  many  generations  to  lejim 
rse   influenced  verv  little,  if  at   ill 


'over  complaine 


wen 


a  case  Of"  ordinary  fever  alioMt   th 
ry   is   now    hetter  expend 


('(I    iiu 


middle  of  tlH>  last  centu 
trained  nurse,  with  infinitely  less  risk,  and  with   intiiiitel 
.-•■reater  c  mifoi't  to  tli<'  patient.      Of  the  difficulties  inhennt 
in  the  art  not  one  is  ,so  serious  as  this  which   rehif,.^  i,,  th,. 

iiiif\ 


cur<- of  disea.se  hy  dru,o\s.      There   is   so  much   uncert 


and   (liscoi'il 


even   amon-f  the    Iiest  autlusrities  (u) 


Dssentials  it  is  ti-ui-)  that  I  al 


ways  feel  the  force  of 


could  not  (|Uote  in  the  tender  ears   )f  student!' 


ton  iimi- 
n    wrll- 


own    stanza  in   "  IJahlii   B,.,i    Ezra,"  which    I 


lOA'CNTI-, 


One  of  the  chief  roa.sons  for  tl 


lis  uncertaintv   is 


^easinj;-  variahility  in  the  manifestations  of 


I  /II'  ijii- 
li 


an\-  line  .!!■,- 


ease 


Ls  no  two  faces,  .so  no  t 


wo  cases  ai-( 


respects,  and  unfoi-tunately  it  is  not  only  the  .1 
which  is  so  varied,  hut  the  suhject^  tfiemsel 
liaritics  M-hich  modify  its  action. 


isea> 


III    nil 
■  it-  II' 


\('S   have  pn.u- 


With  tl 


It'  'limiiiislicil  ivl 


i.-iiice  u 


.1  ivtiii'n  witli  pioHt  to  the  old 


poll  .Iniirs,  tl,,.,.,.  has  1 


liatli.s,  and  tVictioiis,  th- iv:n..li...s  witl 
Asclcpiadi's   doctored   the    J 


t'l"  iiicjisiircs  of  diet. 


)i'(ii 
|'X('i'cis( , 


\vliieli  tli(.  I!vth(i 


lirst  L,ciitury.      'I'hoiinl,  used   Ics.s  f 


loiiuuis  so  sncccsst'ii! 


ijii 


w  yivcii   with    iiiHiiitcIy 


VciiiU'iitiv,  II 


man 


y    III    th( 


iTrilti 


i''dieiii(.s  ari 


tlioir  indiuitioiis   and  fontmd--ctions,   and 
i.y  (ivvcrsino.  the  proportion  ,jf  iiftv   vcai 


'•'I'  slsijl  :  M-,.  k\u,\v  l„.tt 


vv 


one  diiiiiancd  iiv  dosji 


>,U.  one  Iiuiidi 


Wf  may    salVly 
>>  »M'<i)  that  for 


any  of   tlic    difficulties    w) 


'I'll  arc  sav( 


I'l'latc  to  t 


II'  llll'll     wlu 


'"•li    surround    the    sulijcct 


IS  well  as  the  .saddest  mistake  is  ti 
lis  \vv  doctors  do  oft, 


imictice  tli(.   art.     '1 


MIK 


tl 


>  mist;l 


Ke  on 


III'  commonest 
I'  s  prof(.ssion 


\no\\ini4-    it.     Tl 


icrc    nvc   mei 


^'"  ''"""nh.son f  „s  without 


jii'i'liininary  education 
the  f 


who    ha 


ve    iii'Ver 


imdamental  truths  of  t 


winch   would  ,.iiai 


th 


lal.le    (1h.||i    t> 


I  Lirasn 


IS  hased 


OtI 


"■    ■'^L"l'''l< 11     which    Illed 


that    heiit  of  mind  wl 


"■i-s    h.'ive   poor   teachers,    ai 


ICIlie 


I'lhuatioii  ;     jthei 


iicli    is   the   all 


id    never 


receive 


ill::-  th 


at  tl 


s  ayaiii  fall  <.ai 


iinportant  fact 


or    III 


el'  know    it 


ly   into  the  error  of  tl 


nils 

I'NlH 


takes  or   tl 


liellefitillM-    ||,,i( 


'  1 1 1  k  - 


leir    suc(i>s.ses,    mis 


her  l,v  tl 


rii'iice,  and    di<.   I 


nss   the    vei\- 


tliiy  started.     'I' 

"ho  practice  with  their  I 


in-n-,.!.     f, 


essence  ( 


if 


leir 
.f  all 


possil 


'li',    cuaii    w 


»■'•''  ;>i'i'  only  two  sorts  of  doctors  •   tl 


leli 


tl.'i'ir     tolliriK 
wishes  t 


ii'ains,  and  tl 
'I'lie    studi(Mis,    hard 


lose  who  practice  \vith 
workiiiM-    n.aii    who 


'>  know  his  profes,sion  thonaiohlv,  who  | 


I'^l'it.ils  and  dispcni.sari 


ives  111  tl 


I's,  and  who  st 


aiH 


pl'ilosophieal   concepti(,ii   ,,f  d 


ri 


ves  to  olitain  a  wiih 


ISl 


";"  ''"^'»l'Hr<l,struy.K.,and  itmavtaL 


'ise   and   its  processes, 


'"'"ii'  he  hecorne.s  .successfid  •   j 


""•'•'"iiks,  and  oiitweiul,  scores  of  tl 


ke  years  of  waitiii^' 
nt  such  form  the  hiilwarks 


lil'ix   tllems(.| 


Ni'Wof  the  difficulties  hound 


vcs  into,  and  often  ,,„t  ,,f,  j 


IC  Volul(le( 


asios  who 


iractii 


111    which    we    doctoi 


111' with  the  "foohn,dtit,„|, 


iiiixid   an<li( 


'lice.      Coi 


'.s    Work, 
niiioii    sei 


hesitate    to    speak 


''"''■■  ""il  is  usually  in  ii 


ise    111 


lattei 


III    a 


■s    medical    u 


tidii 


siippo.se  as  a  Ixidv,  cl 


iv.Tse  ratio  to  the  deerce  of  ,.d 


iiea- 


ei'ii 


lyincii  are  hotter  educated 


I 


tl 


laii  Hiiy  (itlici',  \-ct  tli('\- 


10 


uiituriniis  sn]>[)(>rf('iN  ni'  all  tli 


fitii 


iiostruins    mid    Imiiiliiinnviy    with     wliicj.    the    <lfiil\ 
ri'lii^ims  pain-isal.oniid,  aii.l  1   lind  that  the  t'uithci"  uwav 
they   liavc   waiidci-cil    t'loiii    the   d 


I'crccs    of   the  Couiioil 


Trent  the  iiiorc  apt  arc  they  to  he  steeped  in  tliauiiiatuivi 


and 


(Jal 


eiiieal    su])ei'.stitioii.      Ihit   Uiiow   also,  man    has  an 
iiilioni  ei-aviii--  for  ineilieinc.      ( ifnei-ati(*iis  of  hei-oie  dosiiiL; 

li  ;i  thii-st  that  even  3'(.uii(r  infant- 
ha\-e  licen  loiown  to  er\-  \\<r 
ore  reniai'l\ed,  ,lie  dcsiiv  \n 


Hi 


•('  yucn 


his  t 


issues  sue 


in   the  hli;llel-  cir( 
certain  druii- 


'<Mes  of  soeicl  \' 


tak 


As   I 

tl 


once 


l.ef 


e  niedieiiic  is  the  one  feature  which  distin"ui.si 


les   Ilia  I 


the  animal,  from   his  fellow  creatni 


It 


is   real!',  on( 


most  serious  ditliculties  with  which  we  liave  tocont 
which  would   yield  to  dietiiin- 


clIU. 


veil  m  minor  ailments 


louniit 


to   sinijile  home  remedies,  the  doctor's  visit  is  not  tl 
to  l)e  com|)lete  without  the  presci'iptioP.     And  now  that  tl 
])liarmacists  liave  cloaked  even  the  most  nauseous  reiiiedi. 
the  temptation  is  to   use   medicine   on   everv   occasion,  .m 


I   fear  we  may  return  to   that  stat- 
emancipation  fi-om  which  has  liccn  i 


iini  and  his  followers  to  the  r 


ICC 


As  tl 


'ypharmacy.   ih 
■  ,yift  of   ilaliiic 

le  puhlic  liccnllji' 


more  cnlii;litened,  and  as  we  j^-et  m(a-e  sense,  dosin^'  will 


recoi;ni/.«(l    as    a    vc 


ry   nnnor    function   in   the  practi 
iparisou  with  the  old  ineasui-esof  Asclcp 
After  all,  these   dilliculti's — in  the   suhiect   itself. 


nieilicnie  in  con 


III    II- 


MIKl      111     \(U1- 


are 


less  ,.ii>i;-  j^raduailv,   and 


We 


liiuc 


consolation  of  knowiiiff  tlint  \-ear  liv  vear  the  tot, 


II  aiiMHiiit 


)f  un 


inecessary  sutieriii!;-  is  decreasiiiii:  at  a  rapid  rate 
In  teachino:  men   what  iliseasc   is,  how    it   may   h 


vented,  and  how  it  mav  he  cured,  a  Ti 


iiversit\-  is  fultil 


one    o 


f  it 


S    Ver\'    IIOMlc 


-t   functioi 


is. 


I  as 


and  the  splendid  e\aiii|ile  of  such   niei 
land,  (  an'iphell,  Howard,  Hoss,  Macdonnel 


1", 

'I'he  wise  instruct iiiii 
Holmes.  SllliiiT- 
,  ami  otllelS  ||,i\r 


ca 


rried  comfort  int(j  thousands  of   homes  thnaielioiit   liii- 


and 


The  h 


'uetit: 


s  derived 


tr< 


an  tl 


le  increasi'd  faciliti 


the  teaching-  of  m 


edicine   winch  have  come  with  tl 


■ivat 


chan,i(es  made  here  and  at  the   liuspitals   during   th.    uast 


}• 


11 


t'CflMv   (illr  (if 


•"^' ^'7"- "•'" ,7^  •' "'^'"•"'f"tlH.,.|tix,.ns„rtInstuwn 

I'ntvv.lMM.w.l.ly  ,lifl„s..u  ,,,,,1  iVlt  In  .vnv  lu..alitv  to 
wind.  til..  -,a,luatrs  ,,f  this  s.Ihm.I  ...uv  ■.>.  ;  an,|  rv,.,  v  u-Ut 
^^l'"'l'  I'>''M„.,t..s  hio.h,,,  ,„,,,;,„,  ,„,-„,,j-,„  .,,^^1  ■^,-^^^^ 
'•nal.les  tlir  nu.li.al  faculties  tl.r.mol.out  tl,.  ,„uuiyv  tn 
tnn.  ..ut  Lrttrr  ,|„ctnrs,  moans  IVuvr  niistak.s  in  .lia..n'„sis 
.uivatiT  sk.II  -n  .l..aliMo-  witl,  ..n...rnvM,.i..s,  a,.,|  tl,,.  vuin'n' 
'■:  1'^"'.  au.l  >,usu'ty  U,  .•nuMtl-ss  s.^l.,,  ;.  a.ui  tl,.!,-  tn,.n,ir 


Tilt!  physician  i 


wiii-k  is  arduous  and  coniiilcx,  i 


"vdsaclcar  h..ad  and   a  kin.!  heart  ;  hi> 


\-i'i 


y  hijfhcst  I'acultics  ol'  ti 


i'(|Uinni;-  the  rXiTcisr  ., 


fth 


II'  mind,  will! 


•onstaiitly  anj 


ci-niii 


.\t  1 


iiii^'  to  the  emotions  and  tiiier  f 

iiiHiiene..    Imvii    nioiv   potent,  at    no   time    has   1 

I'i'WHful  a  factor  r,„- good,  and  as  it  is  one  of  tl 

|ii)ssihle  duties  of  a   e-j'cat    I 

I'aNin^',  so  it  will  1, 


)eal 


<'  time  has  hi- 


le     heeii 


ni\el'sitv    to    fit 


liyhest 


lllell     1(11-  thi> 


cuie.  to  carry  on  the  i 


V-nrhii-hest  mission,  student,- 


ot    llledi- 


lid  death,  hett 


H'Nei'-eiidine-  warf 


•■!•  <'i|mpped,  ahlci-  men  tl 


sers,  liut  animated  wit!,  tli 


ii'c  against  di 
lan  ynnr  pivdi 


sease 


'pes,  '■  for 


llope  of 


''If  spirit  and   sustained  l,v  tl 


leiv 


\Vf  heal-. 


cxcry  creature  is  tli 


I'  hjinner  that 


Miversitv  is  totl 


iinl 


The  other  function  of  a  U 

■uirent  knowledu-e  in  ail  -lepartnients,   teacl 
'y  which  the  .slaf 


cacliiiio' 

Uii    the  steps 


nvj;  In 


•■"ilcnv    facuiti 


"s  jnursm.s  lias  heen  reache.l,  and  teacl 


'W  to  teach,   form  the   lout 


iiie   work   of  tl 


es,    winch    mav 


iiiaiiiier  \>y  men   who  I 
tliiir  suhjects  to  know  that 


ic   vai'ious 

'"'    '•'>"<■   i"   n  pri'functory 

liiv.'  nevei'  "■one  .!c..p|y  ..uouoh  into 


111  any    way   ii 
I'liiiftion  of 


nportant.      What   J 


ivally  thinking-  ahout  tl 


lem  Is 


I  I  I 


nean   l.v   the  tliinl 


corps  owes  to  enl 


Work   of  th 


"v.'rsity,  is  that  duty  which  the  prof 
irj.e  the  IxHindaries  of  hunian'knowled 


Kill';' 


cssioiial 


fiiiil 


itt 


IS  sort  makes  a,    ( 


niversity   oivat,  and 


\\\ 


aciiltv.     Tl 


"  exorcise  . I  wi.l.>  inriuencc  on  the  mimls  of 


t.ind  to-day  at  a  critical  point  in  the  1 


alone 
moil. 


list 


ikrli 


"^  oquipinont  for  toacliinir,  t 


Ol 


yofir.s  of  hard  stni<v.pl 


o  s 


"j'piy 


y  of  tl 


lis 


which  has 


am 


I  with  tl 


10  co-oporation  of   the  ( 


y^no.  IS  appi-oachino-  comploti 


"oiieral  and   the    I 


on, 


loval 


i 


12 

Victoria  Hospitals  students  can  o))taiii  in  all  l.ranclii's  ,■! 
tlioroujfh  traiiiiiiy-.  \Vc  liavc  now  miclicd  a  position  i:i 
wliifli  thf  hiylu'i'  university  work  may  at  any  rate  Ik-  .lis- 
cussed,  and  towards  it  proorcss  in  the  future  nmst  trrii,| 
It  may  seem  to  he  diseoui'anino'.  after  so  nuieli  lias  li, ,  i, 
dono  and  so  much  lias  lieen  so  ovm.rously  niven,  to  .-„n 
that  there  remains  a  most  important  fuMeti(ai  to  foster  an!  1 
sustain,  Imt  this  aspect  of  the  ipiestion  must  he  eonsidciv,! 

"'•'*■"  'I  •'^t-'' I  lui'^  reached  a  certain  stao-..  ,,f  dcveiopmnit. 

In  a  progressive  institution   the  changes  come  slowlv,  tlic 

l)ace  may  not  he  perceived  hy  those  st  conceiiied,  cxcpt 

'  on  ..such  occasions   as   the    present,    which    serve    as    l;m,|- 
inarks  in  its  evolutitai.     The  nicii  and   metliods  of  the  >>M 
Cote  street  school  were  hetter  than   those   with    which   t\\v 
faculty  started  ;  we  and  our  ways  at  the  new  huildin-  ,.ii 
University  stiwt  wore  hetter  than  those  of   Cote   stn.i  ; 
and  now  you  of  the  present  faculty  teach  and    work    iiiuih 
hetter  than   we  did  ten  years  a,i,'o.      Everywhere   the  old 
order  chann-eth,  and  happy  those  whc  can   chanov   with   ii 
Too  many,  like  the  defeated  gods  in  Keats'  Hyperion,  un- 
ahle  to  receive   the  halm  of  the  truth,  resent  thi'  wise  wnuU 
of  Oceanus  (which  I  ipioted  here  with   very  ditfeirnt    IV,. |. 
ings  sojue  eiirhteen  years  ay,)  in   an   introductoiy   lectiiivi 
"Still  1)11  our  Iu'cIn  ,1  lifsh  iicrlcclidii  (icjuls, 

*  *  *  *  l)01'll  of  lis, 

Kati'd  to  cxi'i'l  u.-<." 
Now   the  fresh  perfection  which  will  tread  on  ,)ur  li.,  I, 
will   come   with  the    opp,)rtunities    i'oi'    hjoher    uni\,  isitv 
work.     Let  me  indicate  in  a  few  words  its  .sco[)e  and  iiims. 
Teachers  who  teach  ctu'i'ent  knowledoe  aiv  not  nec,'s>,ii  ilv 
investioators;  many   have  not  had    the  ne,>,|ful    trainiiin': 
others  have  not  the  needful  time.     The  very  h,.st  iiistin,t,,r 
for  students  may  have  no  C()nce])tion  of  the  hiolu'r  liii,>  of 
work  in  his  h.-anch,  and  contrariwise,  how  man\-  luillijini 
investigators  have  lujen  wretched  ti^achers  ;•     lii  ,i   s,!,,,,,] 
which  has  reached  ihis  stage  ami  wi.shes  to  do  thinkinu  as 
well   as  teacliing,    men  mu.st   he  selected  who  are  nni   ,,nlv 
thoroughly  nwvuuniiil  with  the  hest  work  in  tluird.pait- 


18 


nil  inir  Ih'ils 
'     Ulli\(i'-.ity 
[>(■  aiiil  iii;ns. 
'   iii'(.T>Mirily 
111    trniiiin^-; 
st  iiistnictiir 
;'li('i'  liiirs  III' 
my  iirilliaiit 
III  a   scIkhiI 
tliinkiiio-  us 
I'c  imi    ,,nly 
lii'ir'|i'|iiirt- 


niriit    tlic    World    ()\ 


<•!•,    Iiiit    wl 


II)     fllsi 


.Miiil..t.(m  mill  ...irruy  t„  ,,„t  tl„,n  intof 


.•will,    I'lU-ll    olir    III    I 

M 


MS    spin. IV,    tn    tllr   stniv    nf 

'<"-'"l.'.l-..     Mm   of   tills    stmiip   nloni.    coiif 


'    l"i\<'    ulcus,     witli 
••I't'i'.     iiini  who  can 


tl 


ic   Worlds 


"I"'"    "    -"Vc■■s,t^•.      Tlicy   .should    l,c    so„<d,t   I 
^vi'I-:  an  iii.stitutioi,    u-hicj,    wraps  itself  ii?  St 
•lll'l    lines    not    |,,o|<    lu.yond    the    ci.r 

I'll. IVssors  may  „vt  ,i;ood  tcnchcr.s,  I 
() 


>'V    "ivati 


less 


'•■   fur  and 
raho's  cloak 


lie   o 


f  Mic  chief  difliciilties   in    tl 


,i;ates  in 
ut  rarelv -ood  tl 


selectin^r 

1  i  11  k  e  rs 


is  the  stress  of  I'ontiiie  cl, 


w 


liich   often   saps   tl 


tllllle'S. 


"■    ''liernirs    of    niei 


"■    "'ly  of  advanced 
iss  and    lal.oratorv   duties 


lici'e  are  twi 


I  capalil 


the  profes.sors  plenty  of  assist 


sseiitial   |)r( 


e  ol     lilirhej- 


'Visions,   fii'st,    t 


o    invc 


Wiil'll     o 


"t   witli   teachings  and,  .second 


"lice,  .so  that  th.y  will  not  I, 


iiiiiil  to  n-radimtes  and  others  t 
llieir  direction.      Witl 


to  !>i 


\'c  elK-oiir; 


II  system  of 


"  <'ni'iy  on  researches  mid 


er 


''"'■•ii'ships  11  iinivcrsitv  niav  1 


illowships  and  ivsearch 


liive  a   liod\ 


""■'I.   who    on    til.,  outpo.sts  of  knowledi 


"I   alile    \-o|]ii 


Mll\e\||ii. 


\M\fil  ami  \isi 


'diii 
isili 


!!<;•  and  correct 


ini!' 


Til 


si^ii  that  a 


,''     'ire    explorilio- 

I'll'  Work  istheont- 


uiiiversitv  is  thi 


""ii"l'''l  I'V  fi   i^Tonp  of  lirin-ht 
ill  ••iilvanced   methods,   m-t  onlv 
stiiimlatod   to  .lo   his  he.st  work,  lait    1 


•ikiiiy-.      Sill 


.vniiii-  minds,  well   trained 
IS   the    profe.s.sor    him.self 


iiiclil  and  to  know   what  is  st 
'w  II  iloiiiaiii. 


ic    has   t 


o    kei 


■p  fi 


iiTin-'  III   every  part  of  hi,. 


With    tl 


IC    wi.se   co-opei-atioii    of   tl 


.\ 


il'il  anthorities  Montn^al  sh.aild  I 


'"  •\""''";'.  a  orcat  medical  centre  to  which 

ii,y,    who.s..    lahoratories    will 


11'  university  and   tl 
'cconie  the  |< 


le 


'I'  Miiuiii   leanii 


st   stiidcnt.s,  and    whose   teacl 


line-  wil 


■mils,  universally  recounize.l  as  of   the  hiid 
iirsi    type. 

Now  I 


clllllMiri;li 
men  will  flock 
attract  the 
'ri'^  out  into  all 
lest  and  of  the 


"'•'''    is    the    outlook 


MelJill.      What 


past 


more    eiicourai 


(luy;    than     at 


;1TSS  lit     tl 


,yuai-antee  for  the   future  does  tii 
'  cade  afford  .'     No  cit 


le  nro- 


(le 


'"'^  -  lilierally  endowed  lii,i.|icr  education 

""^v  to  io.ster  that  undeHiial-le  .somethin.-  wliiel 


1 
y  on  this  eontiui'iit 


lere  remains 
1,  for  want 


► 


i 


'i'  il    lii'ttil-   tiTI 


II.    \M'    I'llll    tile    Ulli\C|>ity    S|,i|it,   il      s cti.i 


winch  ;i  iicli  iiistitulidii  may  11.. (    have,  and    witli    wliicl 
pnnr  i.iir  iiiav  lie  satiiratcil.  a  siaii.tliin--  w  I 


'',V 


I   .'I 


Willi  men  and  not  witi 


iicli  IS  aNsiiciat. 


ill  Ml 
ihl 


1  iiKiiicy,  wliicli  caiiiint  lie  piirclia 


iii;irl<('t  111' yi'dwii  ti>   urilcr,  lait    \vl 


IK'll    colllt's    111 


.SM)I\-  with  |(i\-, 


\Mtil"llt    Whicli    .\,'l,,ishh 


sol 

si'll- 


ili'\<>tiiai  to  duty  and    I..   hin||    ideal 


s,  ainl 


"  is  w  ritti'ii  (ill  its  |Mirtal> 


H   siiiiicti.i,!^ 
vitli    wliicli   ,, 

I  is  il>s()ci;lti.| 
III'  [iiircliast  .i 
follies    iliscii- 

II  i'lriils,  iill'l 
.l-t;ils. 


> 


I 


CLui\J 


Case  of  Sporadic  Cretinism  (Infantile  Myx- 
oedema)  Treated  Successfully  with 
Thyroid  Extract. 


BV 


WILLIAM    OSLER,     M.D. 

Professor  of  Medicine,  Johns  Hopkins  University 


FROM 
ABi""Mi\rirc!  r»i? 


February,  1895. 


►l 


^ 


i 


:'■ 


CASE   OF   SPORADIC    CRETINISM    (INFANTII  K 

MYXfEDKMA)    tri.:ati;d    SUCCESSFUI  fv 

WITH  THYROID  I'XTRACT. 

BV    WILLIAM    OSLKk.  MD, 

l'r,.fuss„r„l  .MHicine,  John.  Hnpkins  liiiv.rsiiy. 

In  my  paper  upon  sporadic  cretinism  in  America  read 
before  the  Association  of  American  I'liysicians.  in  May 
189;,,  I  reported  three  cases  of  this  ilisorder.  One  of  these 
which  had  been  under  Dr.  Hooker's  observation  subse 
qucntly  passed  out  of  sight.  The  other  cases  haVe  been 
treated  with  the  thyroid  extract.  In  the  girl  aged  nine- 
teen the  treatment  has  not  been  ve.-y  .systematically 
carried  out  by  the  patients,  and  the  condition  has  not 
materially  improved. 

In  the  third  case  the  results  have  been  truly  remarkable 
I  give  the  notes  in  full  from   the  American   Journal  of 
Medical  Sciences,  Nov.,  1893. 

M..   aged  two  years  and  three  months,  was   brought 
to  me  first  from  the  Eastern   Shore  of  Maryland,  Jan- 
uary 10,   1892      The  parents  (fir.st  cousins)  are    healthy 
and   strong.     No    hereditary    ailments    on^  eithe     side^ 
no   members     of     the    family    have    had    goitre       The 
patient  \vas  the  second  child  ;  the  labor  was  easy,  and  she 
hrove  well.     Nothing  special  was  noticed  abou[  he  chilS 
until  the  end   of  the  first  year,   when  it  was  suspected 
something  might  be  '.  /ong,  as  she  had  not  cut  her  teeth 
and  did  not  attempt  to  walk  or  to  talk.     Throughout  he; 
second  year  she  grew  fairly  well,  but  had  several  attacks 
of  slight  lever,  and  did   not  develop  as  other  children 
mak.ng  no  attempts  to  crawl  or  to  walk,  and  seemed  un-' 
na  urally  quiet  and  dull.  She  did  not  cut  the  incisor  tee?h 
until  she  was  nearly  two  years  old.     Within  the  oast  six 
months  she  has  chnno-f^H  r^m-,.-!-->i-i    •         •       V      V  ^ 

v^r..  r,  1         J      '  "'^ngf^aremaikablyin  color,  has  become 
ver>  pale  and  waxy,  and  the  face  and  limbs  seem  puffy 


i  !■ 


I   I 


^ 


I 


( 


2  OSLER  :     Cretinism. 

and  swollen.  She  has  taken  milk  well,  and  has  developed 
a  little  mentally  ;  smiles,  and  attempts  to  repeat  her  own 
name  when  it  is  said,  and  has  learned  to  say  '<  mamma  " 
and  "papa." 

Present  Condition.— Under -?.[7.ed  child  for  her  age    As- 
pect is  very  striking  ;  color  pale  ;  face,  very  broad  across- 
the  mouth  is  open  ;  tongue   protrudes,  and   is  evidently 
enlarged  ;  the  lips  are  full  and  heavy  ;  the  cheeks  ver'v 
large,  almost  pendulous  ;  the  hair  is  almost  straight  •  the 
eyes  are  blue  ;  the  sclerotics  very  pale  ;  the  eyelids  glossy 
and  infiltrated     The  forehead  is  large,  not  badly  shai)ed 
the  head  well  formed,  rather  prominent  behind  •  the  an- 
terior fontanelle  is   not  qjite  closed.     She  looks  "ood- 
tenipered.  but  takes  very  little  notice,  and  smiles''  in  a 
feeble  way.     The  facial  aspect  is  that  of  a  cretinoid  iihot 
Ihe  muscles  of  the  arms  are  feebly  developed  •  the  sub- 
cutaneous   tissues   are   much    infiltrated  ;  the  hands  are 
swollen  and  glossy— not  tense,  and  look  (edematous   hut 
the  infiltration  is  firm,  and  only  yields  on  prolonged  pres- 
sure.     The  legs  look  large  ;  the  thighs  present  several 
folds  ;  theskin  looks  glossy,  and  the  subcutaneous  tissues 
are  much  infiltrated.     The  skin  over  the  dorsal  portion  of 
the  feet  is  very  glossy  and  tense,  and  on  firm  pressure  nits 
with  distinctness.  1  he  abdomen  is  distended  and  the  sup- 
erficial veins  prominent.   Palpation  is  negative  ;  the  cd^e 
of  the  hver   is  palpable  about  six  cm.  below  the  cosul 
margin.    The  edge  of  the  spleen  is  not  palpable,  nor  does 
the   organ    appear   to   be   enlarged.     The  thora.x  is  well 
formed  ;  no  trace  of  rickety  enlargement  of  the  ends  of  the 
ribs  ;  no  evidences   of  rickets   in   the   long  bones.     The 
apex-beat  of  the  heart  is  just  within  the  nipple  line    There 
IS  a  systolic  murmur  with  the  first  sound,  which  is  loud 
and    intense    at   the     pulmonary   cartilage  ;    the    breath 
sounds  are  clear.     There  is  no  enlargement  of  the  super- 
ficial  lymphatic   glands  ;    the  thyroid  gland   is  not  en- 
larged ;  the  cricoid  cartilage  can  be  well  felt,  as  tan  also 
the  entire  trachea  as  low  as  the   sternum,  and   it  can  he 
taken  between  the  two  fingers  quite  plainlv.   Dr   Ilalsted 
thought  he    could  feel   the   thyroid    beneath   the  sterno- 
mastoid  muscle.    The  percussion  note  on  the  first  bone  of 
the  sternum    is    clear.     The    examination    of  the  blood 
showed  a  moderate  increase  of  leucocytes  and  some  irre... 
ularity  in  the  .size  of  the  red  blood-corpuscles. 

The  condition  was  diagnosed  sporadic  cretinism  \s  it 
was  evident  that  the  blood  condition  of  the  child  was 
very  much  below  par,  she  was  or^lered  the  syrup  of  the 
iodide  of  iron. 


OSLER  :     Cretinism.  , 

March  I,  i893.-Patient  brought  again  to-day      In  tho 
year  and  two  months  which  have  elapsed  sincfl  saw  t  e 
child  she  has  improved  remarkably^     She  ?s  now  three 
and-a-half  years  old.     Her  height  is  7rcm      ^ 1 1  i     i 
"?°->;<^".if-t,  takes  moreno?icland\hefociaUxpres' 
sion  IS  decidedly  brighter.     She  tries  to  say  a   ewvords" 

:;:  kinl'  ^^Zl^:Ztl:'f  ^  ""'^  --tanVe.^Thrmtt 

fnSSSdTe    eni^gof'll''"^ 
u-  1  ^'iiiig   ui   in         m  subcutaneous  n»Hfma 

which  was  so  marked  a  feature.     She  still  has  a  liSle  ?J 
filtration  about  the  eyelids  and  cheeks.     The   imbs  a  so 
look  full,  and  they  are  firm.     The  skin   is  /  k/hT    , 
over  the  hands  and  feet      The  "on^nL  H-^  .      ^  °' -^ 

so  often  from  the  mouth.  S;lgh^?l:n'S:  ?a°c?i;rre^ 
pose  It  IS  frequently  seen  protrtding  slightly      The  face' 

11    rednoid     head  '"'  ''"  expretsio.r  an'd  aspect  ar: 
still  cretinoid  ,  head  is  51.5  cm.  in  circumference   the  -ih 
domen  54-5  cm.     The  neck  is  thick  and  S^kid  ore' 
sents  a  large  tranverse  fold  nf  f^t      tk       ^""'l,  ana  pre- 
not  palpable,  and  below  the  thy^^^  f  ^"f  '^ 

can  be  felt  with  the  greatest  dis^h/clne"  '  .X'^s;:;:,'^^^:^ 
tween  the  fingers  down  to  the  sternum  ^'^""P^^  ^c- 

^^Ir'A.T  rS'  ^'^'  ''^^'■°'^  ^•^'^'•^'^t  was  begun  in  March 

The  child  was  brought  to  me  on   Anril  "S    rQr..      ti 
change  has  been   of  an  extraordinary  cln"r,'ce?'^\nl' 
manifest :  first   in  entire  loss  of  the  c?et  noi  Us^ 
colons  good,  the  nutrition  evidentlv  verv  rnV,  -I,  i?^      '     f 

'  q'lui),,  anu  in  the  totirteen  months  whiVli  i,>,.„     1         j 


ti 


i"ugh   she  is,   of  c 


lere  was 


an)'thi 


ourse.  still 


ng  peculiar  about  her 


undersized,  undeveloped 


M 


► 


"^  OSLER  ;     Cretinism. 

The  case  adds  another  to  those  in  which  benefici-,1 
effects  have  followed  the  administration  of  the  Xrofj 
extract  in  infantile  myxoedema.  tnyroid 

Oct.  1894  —The  improvement  in  this  case  continues  r 
saw  the  patient  again  in  July.  She  is  a  very  brig?  active- 
child,  in  whom  no  one  would  notice  that  tLr^  w  k 
anything  wrong,  and  in  whom  no"ne  would  nodce  'm" 
thing  amiss  except,  perhaps,  that  she  does  not  talk  as 
plainly  as  a  child  should  at  her  age. 


i 


ur  years  and 

ch  beneficial 
the  thyroid 


continues.  I 
bright  active 
:re  had  been 
1  notice  an\-- 
not  talk  as 


■5  I 


^ 


Archives  of  Pediatrics 

A^         n    DILLON   BROWN,  M.  D.. 

Adjunct  Professor  of  Pediatrics  »^e  New  York  Polyclinic,  etc. 

This  is  the  only  English  publication  devoted  exclusive! v 
to  diseases  of  infants  and  children  caliusi\  t  ly 

practitioner  '^"  "'''  '^"'''  °'  '^"^  ""'''  ""'"'  ^°^  ^^e  general 

It  is  practical. 

It  makes  an  annual  cyclopaedia  of  Pediatrics,  carefullv 
indexed,  of  inestimable  value  for  constant  reference         ' 

«3.oo  a  yeir  in  a'dfrce*'"^'*"""^-      SubscripUons  may  begin  a,  any  time. 

isend  lor  sample  copy  and  catalosu,- 

BAILEY  &  FAIRCHILD,  Piibllshcrs, 
^.^,__,^^_____  2*  Park  Place,  New  Yi.!.. 


CL  /_  • 


TYPHOID   FEVER   IN  COUNTRY 


DISTRICTS. 


BEING  THE  Subject  for  GKNFHit    iw  .^ 


'h'  William  Oshr,  J/  /J) 


RepH.ue..fro.n  u.  M.Kv:...n  M.nxc..  JO.K...,  M.,  „ 


'•'^95. 


iHK  dwellers    in  cities   have  a    verv 
deep    concern     i„    the     prevalence    of 
typhoid  iever  in  country  towns  and  dis 
tncts.     In  the  first  place  vve  treat  in  the 
CUV  many  cases  which  originate  in  the 
country,  cases    which    too    often    ^o    to 
sue!  our  mortality   Inlls.     During  the 
past  SIX  years  I  have  h.ui  under  niy  care 
n  the  public   01- private    wards   of    he 
ohns  Hopkins  Hospital  89  patients  wo 
have  come  from  outside  the  city  li„     s 
The  figures  are  as  follows,  from  a  t   tal 

^01  lit),   ^8;    from    Maryland    outside 
jM,„   County,     .,  ;     ^,,„,,J^ 

I     Secondly,  we  take  our  holidays  in  the 
country  at  the  latter  half  of  the  sun  mer 

«iien  t>plioid  tever  is  most  prevalent 
Suice  we  have  no  means  of  knowing  the 
munber  of  cases  which  occur  an miai  v 
'"the  city,  we  have  of  course  i"  wiv 
01  ascertauiing  how  manv  have  been  liie 
untortnnates  who,  in  seeking  heaUhi 
country  resorts  and  seaside  places  In  e 
foJsei^usillnessandnotLr«;;e„th 


ca:i':r;hrkindiir''^'""'^-"'^'o- 

come  under  mv  nl  .  "'  ""'  "^^^^"eiiti. 
past  five  or  sixVlarr  VI  ITt'"'-'"^/^^" 
•stances    in    which    ,?,'  ^"°^'^  ^^ '" 

family  have  hi 'iNSd"7'''''^ 
-^fence  in  count  ";:;;:il;'"""^  ^'^^' 

Popiilousdislesn   u        1       °"^'^^^"'l' 
typhoid  fe^^rprevaii:'''''^^'^^-^-''^"^"'"' 

for1>u'r  Si'nnlf  '"""'^^  ^--^^  ^I'-'il 

taw;"i!:S\?^;^:;^""-->'^eprofi 

tl.e  prevalence  o-typioidfS"'^^-^  ""'''' 
try  districts.  We  inu ',,"?'  "I-"""" 
statistics   to   the    Ki^n    !'-'''■"  ^°^  th   ■ 

Beard  of  llZ.  \Tfar  Z  ?''   ^'''     ^ 

typhoid^w^S^-?i'^^:^-"-f 

statements  are  to  be  fJ.,,,^^  r"  ''"'^  "' 
^»e  mav  glean  an V  tf  ^''°"'  "'^>^- 
the  incidence  of  tKd'^'^"  ^^°"     ■ 

ties  and   towns  o^th'S^'trr     ' 
like  very  much  to  ask  tl,..  pi  '  ■       "  °"''     ' 

tl.e  Secretarv  of  tl?^  I  i' J^T''"'"  ^"'     ■ 

-thisomission/w?;;^t:?y:r::; ; 


¥ 


> 


treme  importance  and  directly  concerns 
the  health  of  the  citizens.  I  suppose 
the  absence  of  all  facts  relatin<r  u,  the 
subject  is  due  to  an  imperfect  orj;aniza- 
tion  of  the  Hoard. 

While    the    notification   of  cases    of 
typhoid    fever   is  not  com]niisory  there 
must  be  great  difficulty  in  getting  accu- 
rate figures  as  to  the    prevalence  of  tiie 
disease.     We  are  not  a  whit  better  off 
in  the  city.     There  were   257  deaths  (I 
include    the  typho-malarial' fevers)  last 
year  (1894),    but   who  can   tell  us   how 
many  cases  ?     Shall  we  put  tne  niortalitv 
at   10  per  cent,  and  say   2570,  or  at  15 
per  cent,  and  say  3855  cases  ?     We  may 
take  no  small  shame  upon  ourselves  as 
a  profession  that  such  a  state  exist.-..     It 
is  useless  to  .scold   Dr.  Methane  or  to 
abase   the  mend)ers  of  the  State   Hoard 
of  Health.     Such   a   condition    at  this 
end  of  tlie  century  is  n  di.sgrace  to  us  as 
^■^  profession,    and    to    us    individnallv. 
The  Report  of  the  State  Board  to  which 
I  referred  indicates  weakness,  inherited 
or  acquired,  of  a  most  disastrous  (piality , 
and  if  any  member  of  this  ancient  ami 
honorable    Faculty  can    read    the    same 
without  a  lilush  I  am  sorry  for  his  intel- 
lectual medulla. 

The  notification  of  every  case  of 
typhoid  fever  in  the  city  and  tiiroughout 
the  State  should  Ije  .  nibrced  at  the  ear- 
liest possiljle  date.  We  could  then  ascer- 
tain the  percentage  of  cases  which  really 
originate  within  the  city  limits,  and  by 
a  proper  system  of  co-operation  of  the 
County  and  .State  Hoards  everv  local 
outbreak  could  be  studied  and  precau- 
tionary measures  taken. 

A  second  point  which  can  be  discus.sed 
with  advantage  relates  to  conditions  in 
the  smaller  towns  and  country  j)laces  fa- 
voring the  development  and'  spread  of 
typhoid  fever.  Outbreaks  of  typhoid 
fever  in  a  town  like  Cumberland,  in 
which  the  i)eop!e  had  been  drinking 
water  contaminated  by  the  .sewage  of 
from  I  to  [  of  the  i)opulatioii,  are  of 
course  not  remarkable,  lint  such  out- 
breaks are  not  nearly  .so  dangerous  tons 
in  the  city  as  the  smaller  house-epi- 
demics in  councry  places,  which  are  by 
no  means  nnconimon.  In  manv  of  these 
it  is  extremely  difficult  to  trace  the  in- 


fection,  as    the  remarkable  one  wlivJ 
I  I)Ut  on  record   a   few    years    ag,,    '•" 
a    farm    house  in     Harford  County 
which    during  the    months   of   An-.. 
vSeptember,  October  and  Noveiubir  Tl.v 
were  ten  ca.ses  with  four  deaths  ;  kj',', 
these   followed    the  arrival  of  a  iiKilil, 
of   the   family    from   Ocean     Cit\     »;. 
what   was   thouglit   to  be  mahiri;i    I,' 
which  turned  out  to  be  severe  t>  ji'h,.,' 
The  water  sni)])ly  in    this   instanu'  i,",. 
certainly  not  contaminated,  since-  it  »  ! 
used  in  common  with  another  hi ri^ciir 
ily  consisting  of  manv  i)er.soiK';,i '(]!' 
susceptible  age.      Here   the  luo.l  sii|,„vi 
might  have  become  in  scjiiie  wav  iiilVcu'j 
though  Dr.  Sappington,  who  had  ^.i,,,'. 
of  the  cases,  .seemed  to  think  that  it  «i 
most    probably    transmitted    1)\-    ,ii,',.\ 
contagion.  ^ 

A  State  lioard   of  health  of  am  rf 
ciency   would  receive   earlv  lu.tilint.n 
of  every   house  outbreak,   and   uithji 
proper    corps     of     inspectors,    snitihv 
means  could  be  taken  to  l)reveiit,  at  iin 
rate,  difTusion  of  the   i)oisoii.     How  mi 
teresting  it  would  I)e  to  know  just  Im  I 
many  ca.-^es  of  the  di.sease  occurrd  1k| 
antunni  along  the  watershed  .,f  the (;,'„' 
powder  and  Jones'  Kails,  both  rf  u'^nii 
.streams   are    liable    to    pojintidii     \1V 
can  never  be  free  from  daii>;cT  on  liij 
.score  until  the  city  has  conipkte  con.  1 
trol  of  the  streams. 

The  third  point  for  discnssion,  aiulin 
reality  the  most  important  (iiic,  ruLitcJ 
to   the    possible   contamination  Ot'  il, 
milk  supply  of  this  citv.     Hnw  niaiiv  | 
cases  of  typhoid  fever  occur  in  the  tiinii'. 
lies  of  those  who  in   this  St;itf  siipplv 
milk  to^  the  citizens  of  this  town.    0;; 
Dr.  McShaiie  answer,  or  can  any  iik'-:- 
ber  of  the  .State  Hoard  of  Health  auMvc 
or  it  they  cannot,  can  tliev  tell  us  \m 
to  obtain  the  facts  at  oui   next  tvpli.ci 
season     so    that    an    answer   could  1* 
given?     The  dairy   indnstiv,  asive.il 
know,  is  enormous,  and  oiieoftlk-s;™; 
est   import   in   the  health   of  the' ciu 
The  readiness  with  which  tvphoid  !mr 
is  transmitted  by  milk  has  been  iiiiiplv 
demonstrated  :  nor  does  it  iv(iuin' tli;ii:i 
man    ill     himself    with    typhoid  tcur 
should  milk  cows  or  jje  in  contact  wiiii 
the  milk.     A  man  whose  hnv  is  ill  wiiii 


■ 


klie  disease,  or  tlie  woman  wlio  lias  been 
iiiirsiii,^:  her  dauK-Iiter,   may  readily,   Ui 
|si'iViMl  ways,  carry  the  itit'ectiou. 
(I    Asa  iiieilium  ("or  the  development  of 
f*^ the  typhoid  hacilli  milk  is  well   known 
5j;to  he   most    favorable.      It   is  probably 
not  iilone  from  the  water  of  a  eontami- 
vii.iU'il  veil   used   lor  washing  the  milk 
JiMiis  that   infection  arises,  but  in  many 
piiMaiices  from  the  direct  contact  ofdirtv 
[.;  !i,iii(lswith  the  milk  or  with  thy  vesselsin 
r  uliicli  it   is  placed.      The  onlv  possible 
^Mlci^iiard  is  in  a  rigiil  .system  of  inspee- 
hioii  of  every  dairy  which  supplies  milk 
Jiii  the  city,  an  inspection  whicli  should 
|1)-  fre.juent,  systematic  and   thorough. 
I  liiive  no  desire  to  take  up  tbe   ti'ine 
(if the  l''acidty  with  figures  from  other 
>::  liK-alities.     There  are  those  which  show, 
'  ;is  ill  New  V.:)rk  .State,   that    while    ty- 
]iiioi.|  is  progressively  decreasing  in  oiir 
l,i!Xo  cities,  it  is  jirogressivelv  increas- 
ing; in  the  country  districts.    Baltimore, 
widi  a  mortality   from  this  preveiital)le 
olhi'tu'ceti  5  ami  6  per   10,000  of  popu- 


ation,  ranks  with  the  unsewered  towns 
t  le   sanitary    conditions   of  which    are 
still  antuine.      We  shall   probal.lv  never 
reduce  the  death  rate  from  this  disease 
to  tfie  ratio  of  modern  cities  until  the 
cesspool  system  is  completely  abolished. 
Hut    bel^^.re   that   great    work    is   under- 
taken,  the  citizens  should  demand  that 
at  any  rate  the  sources  of  contamination 
''■'.>"!    outside   should    be    reduced   to   a 
■'innmuni  ;    that    our    sources    of  water 
supply  should  be  scrui.ulouslv  guarded  ■ 
and  that  our  citizens  should  be  guarded 
apnist     all      possibility      of     infection 
through  the  milk. 

The  points,  I  think,  which  could  be  dis- 
cussed  with  advar.iage  this  evening  are 

1.  1  he  actual  prevalence  of  tvphoid 
fever  in  the  country  districts  and  smal' 
towns  Uiroughout  this  .State. 

2.  The  measures  which  should  bt 
adopted  to  prevent  contamination  ofoui 
water  su])ply. 

.1-  The  (piestion  of  the  inspection  o 
uairv  farms.  . 


i 

i 

I 


► 


C  Z-l// 


VISIBLE  CONTIUCTfLK  TUMOlfR  OF  THK  PYLORUS 
FOLLOWING!  I  LCER  OF  THE  STOMACH. 


BY 


WILLIAM  OSLHR.  M.D,,  LL.D,  FRCP 

Professor  of  Medicine.  John.s  Hopkins    Univor.sity."  lllt'i...„,,. 


Reprinted  from  the  Montreal  Medical  Journal,  Augwt,  18'J5. 


H 


I 


f 


I 


f)( 


VISIBLE  CONTRACTILE  TUMOUR  OK  TIIK  I'VLORUS  FOL- 
LOVVIN(J  ULCER  OF  THE  STOMACH. 

Hy  WiMiAM  Osi.KR,  M.I).,  LL.I).,   F.R.f".l>. 
Professor  or  Me.licine,  Johns  Hoi.kins  University.  Baltimore. 

In  Stricture  t.f  tl...  ..nHc.-  o,„.  can  n.,t  inFn..,n..ntIy  IVoI  the  con 
tnu.f-.ns  ,n  tit.  ,.n,„.n,o„sly  l,yi,..,.tr.,phi...|  pylnrie  n.^ion  of  tho 
stonmch  In  such  cas.-s  a  wave  .,f  p.-ristalsis  may  hf'  felt,  ,hn-in.r 
which  the  antffo,-  wall  „f  the  .,r.-an  hanlens,  an.l  then,  as  the  wave 
nppr..ache.s  the  pyl.„.„s,  a  Hrn.,  har.l  ntass  n.av  h-  oTasne,!,  which 
|rra,lnally  relaxes  s.,n,etin,es  with  a  ...r^lin.  .,f  ^a.  In  ve.y  thin 
patiet.ts  w.th  n.uch  .hiatat.on  t.f  the  stt.n.ach  the  peristtdsis  is  mulily 
-Ik.  seen  a,.,l  th.>  pyloric  tun.t.ur  ,nay  also  hecu.e  visible.  L,  the 
f.'l  own...  case  the  tuntour  at  the  pyh.n.s  was  ren.arkal.lv  .listinet, 
-M  as  ,t  hanlened  n,  contraction  lift..l  the  skin  i,.  the\.pi.v«stric 
rm  so  that  a  pronn-nent  mass  coul.l  he  seen  even  at  a  'listance 

...t  the  Instory,  and  tho  evt.lont  .nuscular  character  of  the  n.as.s.  nmde 
-   eel  sure  that  .    was  chieHy  .hze  to  the  hypertrophied  nnuscdaris 

I.-  suhse.)ucnt  h.story  of  the  case,  too,  is  of  interest.  Successful 
.i^astre-enterostomy  was  performed  hy  Dr.  Bres.sler,  and  three  weeks 
--•1-'^  y  the  Murphy  h„tton  which  ha.l  heen  us  d  perf  1"  he 
colon,  causinu'  fatal  peritonitis.  *  "- 

•l""'i's  of  rm^tral;na~nc,materu..i.--Pronunent  tunumr  at 
/'///^•.s..  n,/ut./.  relaxe,  ami  mntracts  and  appear,  and  dimppears 
i>"n.a,kthe  .shn-Ddatation  of  the  ^tomackLGastro.enieJ^Z 
Verjoration  of  the  colo>i  h,j  the  Ma  rph  y  hution  '^^^^««««'«2/  > 

Is  Vsiif '"*  ^^'''''"'"^^  *°  ^'''  Johns  Hopkins  Hospital  I)ecend,er 
^^t,  1,S,).J,  con.plaunng  of  pains  in  the  stomach.     His  family  history  is 


(II 


II 


"'■  '"'"  ' "  ' in.y.  witl.  thr  ..xc.«|.ti..n  uF  ,itt.u-kH  ..IM 


I'   IISI'S  (llcnlldl    ill    IIKdIcrutidll 


y.s|M'|),siii 


III  Muv,  |.S!H>,  iit'ti 


ill   Mh'  l.'l't  si. I.,  ul'  til,.  hImI 


ran  iiiiliscifti(.ii  in  diot,  he  liml 


cniiiin 


lik 


Imt  tl 


H'   pIllMs   IVCiniVij    ill  ,1  f,.\v  || 


'iiii'ii.     Thr  iittiick  dill  nut  last 


iitvaryiii^r  intrrviils.     TIh'Y  IukI  no  ivl 


ays  atxl  cdntinni'd  for  nlMnit 


<•  pam- 
■y  '"111; 

a  MKHltli 


,i'i 


was  often  nauseatoti,  h,.  onl 


lation  to  iiiciils,  and  altli..n.di 


to   k'd  in  this   illness  and    lost 
''sc-nption  it  was  evident  that  tl 


y  Kfcasionally  vomited,      lie  w 


as  conhine.l 


Al't, 


^''•ttinn'  up   li,,   ivit   fairlv   wdl 


fonsidemhly  in    \vei;,dit      I'Vom  j, 
le  pain  was  of  \ery  ^M'cat  seveiif' 


exei 


ac 


pt   for 


ini^r  pain  in  the  ai..lonieii.     He  kept  at  work  and 


an  occasional  dull 


throiicrj,  the  snnniK  r  mikI  autiniin 

III  Deeeiiiher,  |,S!)2,  he  a,L,^ain  Lena,,  t<,  1 


was  verv  we 


ill 


like  in  character  and  of  nreit 

foin-  honi's  after  meals  and  lasti for  an  I 


lave  attacks  of  pain,  ei 
severity,  eomin^r  on  as  a  I'lde  th 


'ami 


•ee  111- 


le   wiis 


WMltei'  of  |,'S!»2    !>;{  1 

time,  iidt  .ilije  t 

lar--e  (|uantities  of  food,  afpiart  ata  t 


iiaii'  or  two.     'riironidioiit  lli 


in  the  house  and  in  iied  a  ;,M-eat  part  of  tl 
"wnrk.     Towanls  H,e  sprin-   he   v.anited  at  interv„| 


ar(,'e amounts.      Hesai.l  it  looked  like  tine! 


ime.      In  Mav  he  vomited  hi 


•  lays  afterwards  the  stool 


y  minced  liver  ;  f 


I  III 

or  several 


s   were  dark  an.l  tarry.      After  this  he  n,,t 


fjuite  well,  the  appetite  n'turned,  he  frained  in  weinj 
to  work.     Towards  the  latter  part  of  tl 


it,  anil   Went  Imck 


anen,  which  has  increa.sed 


m 


in  the  leftside  of  the  ahd 

a--o  the  patient  bad  a  return  of  tl 

has   since    vomited    hlood    four   ti 

amount;- 

On  admission  the  patient  looked  a  littl. 
mucous  memhranes  were  of  fairly  ^rood  colour 


summer  he  noticed 


a   liiiiii 


III    Sl/( 


A 


Wee 


10  severe  crampdike  spasms,  and 
I's,   not,   however,   in   verv    lai 


I'inaci.Ued,  hui  the  h'l 


pounds.      K.\aniinati(ai  of  the  (I 


o   iev"i 


Is 


Welnlit     \-2S 


men  looks  natural  ;  the  left 


than  tl 


le  ri.<;ht.     The  stomaci 


Co\-elvd     \,y    the     rilis.       It    di 


loracic  <a-L;ans  is  iieifativi 
•pi^T'istric  re<,'ion  is  perhaps 
I  occupies  a  small  aiva  almost  com| 


11  littl 


llllhT 


llrl 


'■l\' 


S!):ie''  o 


'I.  sec. 


I'  thi'  left  side.     On  d,.,.|,  inspirat 


not  extend   lower  than   th 


se\c|itli 


f  n  a 


n    hcneath    the  costal 


ion  an  eloni-ated  mass  is  IVIt 


r.  i-'ite  of  .s.'d;-  and  tartaric  acid  the  left 


margin.     Afti'r  diktat 


loll    with 


'lu- 


iull 


er. 


Tl 


firm  and  hard,  and    <ra 


ma.ss  IS  now  to  the  ii<rht   of  tl 


'pif.;astric  reidon  I 


leciiiiic 


le   middle   line 


stomac 


hil 


•h   tymi 


s  can  he  felt  hubhlini,'  thi-ouirli  it.      Tl 


lany  is  .i^reatly  increased,  extendiuix   al 


le  t\yi-:\  <j 


icus  and  passes  the  median   1 


most  to  (I 


I''  mil 


ine 


nipph 


Al 


Ot 


•ove  it  extends  nearly  i< 


tlic 


,nspeet,o„  waves  of  eontraeti<,n  are  seen  to  jmss  f.oe,  i..ft 
to  rioht,  and  there  is  a  -listinct  hour-gla.ss  contraction.  Livei  ,i,i,l 
spleen  are  not  enlarged.  At  fU5  a.m.  the  patient's  .stoni.u!,  was 
en.pt.ed  and  washed,  and  the  milk  he  had  taken  at  7  a.m  ca ut 


""•;""'■   ""•'    '""'"tl"'  'li.ninislM.I  i,.  M.nnMMl.      At  I2..W  M,.    .ni\,ut 

...■■k    2.,()  ...... 1    ,.|..ar   l.n.th,  tVu,„    :,.,   ,..    „„,   .,a s  of   ,„....   ....t 

'".ill.  .ilM.ut  tin.  s,.,„..  ainuni.t  of  Liva-I  „.hI  L'.'.O  ,..•.  nf  wnt,r       At  ", :{() 

I'.-...  alH.ut   2:.()  .T.  nf  (h.i.l  ,„„,„s  with  Hn.lv  .livi.|..,|  f |,  v.ll..wis|, 

I'lnvvM  m  (•..!.>„.•  HM.l   with  u   mnn.j.MlMnr,  w-.v  ,v v..,i   '  This  ,v- 

M..t...|  syith   i.l.I.,nwl,uMM-vm.illin  f.-r  ||C|,  .u,l   with   I'tHmuiM's  tost 

'''■.''"'^"';"""';      ''"l'^; ^  ^^•'■'•"   l"'-"t:    lO.r.    U-..-V   „..ntmli.,.l   hy 

M..-.  CO.  .,  .i.-n-Mnn.m!  sn,|imn  hy.lrat,.  s-.h.ti,,,,,  ami  10  cr.  ,f  th..  iuic; 
^liakcn  tlM.nai.rhly  with  ..thrr  w..,v  nrMtraiix,.,!  I,v  |().-.' ,  ,.f ''l..,.!- 
iin.inal  .snijiuni  liydmtc. 

The  pati..„t  was  ..nlcn.,)   (ivc  ymiiis  of  hirarhnnnt,.  of  s,  ■!..  ,.v..l•v 
'"",  """"  j"  '"'";:    .""  '■ •"-''   ''"l-i'lly,  ;,'.i I   in    w.-in,,,  took 

small  .,,,a,.t.tH..s  of    t.H„|   at  s -t  iutn-vals,  an.l   s... |  to  ,  ,•  .|oi„o 

W.I  .  lia.  t,.st  ,n..al,s  always  jrav  a  ,na,k...i  ifcvas.-  i„  tl,.  total 
nciijity. 

S|...cial  attrntioM  was  .liivct,-!  t..  tin-  ....nWitiu,,   of  tl„.  tuMin.r      It 

was    ..xtn.,n..ly    variahl..    i„    ...sitinn,  .i..,a.n,li,„.    .nti.vlv    ..po,/  tho 
.l..^n.,.,.   ,|.st....s,on  ot  tl...  sto.nach.     Shortly  ,.lt....  a,h„issiou  i,  was 

nut,n..l  that  tl...  tmnoM,.  .nass  was  visil.l..  Unn-atU  th.  skin.  app,.,.  -i,,.. 
an.l  .  ,sapp,.anM,.      (...  wafhi,,.-  th.  ..pi^astnc-  .v.noM  an  ..i-sati,  n  o'l" 
tl...  _skn.   to,.k    plac-e,  ns.mlly   .ni.lway    l„.tw..,.n    tl...    nav..l   au.I    ^he 
ms,t..n,.  mrtilaj...,  an.l  a   .l..|init..   t,„„..n,.  pn.j..ct..,l,  whid.  coul.l  ho 
s......  plan.ly  at  so,.,.,  -lista.....  away.     Aft..,-  ,...,nai„in;:  fo,.  tVo.u  half  a 

niM...t..  to  a  „.,n„t..  it  f^m-lually  .lisapp,.a....,l,     (,n  palpati..,,,  wh.-n 

vis.hl..  th.,.e  ,s  t._,  he  telt  an  ..xt,...„„.|y  ti,.,„,  l,„,i,  s.„n..wl.at  sau.s,ur. - 
shap...    ,„a.S8,  which,  as  it  .lisapp..a,.s,  ,...lax..s  an.l  j,r..ts  .soft      Tl,..,.." 
no  yisihl..  pon.stalsis,  t-xc-pt  wh..,,  tl...  st..„mol.  is  inHat.-.l 

""■pat,,..nt,...,„ain...l  in  tl...  h.,spital  th,..,,,.),,,,,,,   j).,,,,,.!,..,-  .aim-.l 

......what   .,.    w..i.ht,   an.l   took    his  f I    uvll.      II..   .as  .Iisi.ha,-....l 

.hum  iiy  7t,l,,  ISIU.  " 

'";   •'H...m.-y    !5tl,    1...   was    ,...-a.l„,itt...l,   ...anplaini,,..   ,.r  a    ..y.y. 

;•; -  •"'"   '",  ^''"  •■I'Wtstnu,..,    y   .,.|i,.v,.,|    l,v    ..ati,.,-.      Wl.il,. 

'>!-.....  1...  t.,.,k  iV.a..  (ivo  t.,  t..n  .grains  ..f  hi,..,.h,.,.,a,  of  s.„la 
'■--y  U.,  hou,.s.  .Sho..tly  aft..,-  a,ln.issi.a,  I  ,na,l..  tl,..  following, 
't..  :  n...  t,.„.,a„.  n.ass  in  tl,..  ah.l.,,,...,,  ..pp..a,.s  an.l  .lis.tp- 
-■s  .IS  tonnorly  ,.ot...I  It  occupi..s  a  positi..,.  to  the  |,.ft  of 
'''V'"'"'"^"  "■•"•■  'J'lK-  variations  in  it  a,...  v..rv  strikin<-  As  it 
-nt,.acts  an.l  l..eo,nos  ha.-,!  it  lifts  th.  skin  \u..l  ca.^I.  then 
H-'ly  sen.     As  the   contraction   ,...|axes  it  .lisapp,.ars,  oft.n   with 

•tU    to  1...  touch.     But  even  in  this  state  tlie  tubular  in.lumtion  can 

s....  '     o  ,\   T,TV7'  '''"'•"'  '""'^''""'  -^^'"''^  ^^■'^^■-  '•*'  P«"-^talsis 
^-1.    t..  the  left  oi  the  tumour  mass  below  the  costal  margin  " 


Janmii'v  2Gtl..  After   1 


iiiviii^^   had  IK)   f 1   siiico    10   p.m.,  the    tiili 


was|,ass.Mlat,S,u..,a,„l2(J(i   cc.  ..f  a  y,.||„ui,sh   l,r<,\vn   MmM   ..f   tl 
'•onsi.sU.ucy  oi-  thi.i  ,n,.„,.l  wvr,"  withdnuv.i  :  o,l.,r  randd.     It  mictrd 
.str()n<,dy  to  litmus  paper,  ami  the  i.iilonx-l 


roactioa  I'oi-  tli 
.1 


K'  lactii-  acid  test.     Tlic  total  acid 


iicin-vaiiiilin  for  acid 


)  ••c.  dcci-iioi'iiial  .sodium   liydi'at(!  .solut 


ity  was  iifutrali.scd  K 


of  JanuaiT  tlic  patioiit  did  not  d 
dilatation  of  the  stomach,  aM<l  tl 
sccii  without  artificial   iutlatiou.     Tl 


ion. 


J) 


iiriniT  th 


!att 


so  well.     Thcro  wasevideiitl 


^er  ])ari 


V  nion 


le  waves  o 


peristalsis  were  i)laiiil 


visilile,  and  was  telt 


much 


furtl 


pyloric  tumour 


was  IK)  lonii-cr 


navel  and  th 


ler  to  the  ri,i,dit,  midwa\-  het 


loo( 


1  tl 


e  costal  Lorder.      Prom  three  to  live  I 


WtM 


■II  th 


u're   w 


rancid,  froth\-   fl 


lours  after  the  tal 
us  usually  f(anKl  about  a  litre  of  vt'llowish-1 


I\|iil: 
row  II 


ukI 


tl 


On  Fehruai'v    hlth   the  f,)II 


K'    ( 


)Utl 


UK'S    () 


f    th 


owiiii;'  note   was  ni 


ade 


MS  nKirniie 


stomach   are    very   di.stinct,   aiul   the    perist 


active,  the   pyloric  outlines  reachincr  nearly  to  the  ri-ht  n 

ic   pylorus  is  not  nearly   .so  distinct, 


llsi.. 


ine 


Tl 


II'   mass 


at  tl 


laiiiiiiilliii 


lony-er    to    lie    felt    1 


lear   the    middle  line,  hut  can   he  made  out 


and  IS  IK 


right   parasternal    line,   evidentiv   covered    1 


portion  of  the  .stomach.      Falpati 


>y   the    distended    | 


111   thr 

U'liiric 


ion 


Oh    the   2(itli    of   Fel 


increases  the  peristalsi;- 


the  .st 


The   peristalsis    was    ver 


iruary    the  patient    vomited   200  cc.  of   I 


V  active 


;a   zuv  cc.  ot   hrii^lit 
iTcater  curvatuiv  of 


till 


oinacli  extends  two  fingers  l.rcadth  l)el.)w  the  hncl  of  tl 


iiour  mass  to-dav  is  far  over  in  th 


le  na\i 


right  liypogastrium.     T 


patient  was  ordered  eiiemata  of  peptonized   milk  and  eg 


only 


tw 


allMuiieii   water  l.v  the  mouti 


■g,  and  iii\('ii 


1,  with   hicariionate  of  sod 


o  1 1  ours. 


2.Sth 


tomach  is  much  reduced  :  the  pyloric  tii 


meiliau  line  :  there  is  no  peristalsis. 

•March  2iid.  The  patient  has   ha.l   no  ni< 
lietter.     Th,.  alidomeii    look.s   natural  ;  there    i 


a   e\i'|'\' 


nionr   is  ni  || 


)re   vomiting,  and  is  iniicli 


p3'loric  tumour  is  todav  iust  ah 


Th 


Th 


contraction  and  relaxation 


patient  during  this  attack  liaslo.st 


s   no    peristalsis.     T 
)ve  and  to  the  right  of  the  uiiiliili,i 
ire  apparent  to-day. 


I'M  pounds  on  till'  l.Sth  :  I 


ill  weight.     Thus  he  wei-lir,| 


le  no 


M 


tl 


arch  r)th.   Patient  insists  on  goin<>-  1 


w  only  w(>ighs  128  pounds. 


)ine  ;  he  has  hecn    lietter  i'i^v 


le  past  f.'w  day.s.  The  dilat.ition  of  the  stomach  has  verv  nmcli 
lessoned.  The  pyloric  tumour  is  situated  just  helow  the  en>irn,iii 
cartilage.  Xo  peristalsis  i.s'.seen.  Th.'  .stomach  hulgres  just  lir,i,,itli 
the  I.'ft  costal  margin.  The  tum.air  mass  is  not  nearly  .so  van.Mc 
and  almost  constantly  hard  and  h'rm. 

Remarks —This  case   presented  many   points  of   interest,  and  was 


shown  ropeatc'dly  in  tlic   wmd   flass.'s 

history   of   .lyspcpsia,  tlu-    u-astrajoic-  attacks,  t'l 
(luantities  of   l.loo,!,  and   the  persistent  1 
juice,  pointed    unniistakal.jy   t 
tVatine  of  special  conniieiit.     T 


lie   aii'e  o 


>f  th 


patient,  til 


le  vomititii 


lyperaciditN    of   tl 


"   ulcei'.     The    t 


if    laro-e 
le   yastric 


phantom  character.     Jt 


K'  most  ri'Miaikalih'  p| 


iiiiiour    mass    was    tho 


lennnion   was  its 


the  ;iavel  ami   tiie  ensiform  cart 


w.Hihl  lift  the  skin  in  themi<ldlelinr   I, 


WCMii 


triinsvei'.sely  ])laced.  an 
lastin<r  for  from  half 


ihii^^e,  a|>pcfirini;-  as 


d   Wfls  then  to  the  t( 


■linitr  tnm 


our 


a  ndnnte  ti 


oiieh  Jirm  nnd   hard.      Afti 


MiU',   with   .sometimes   an 


'  ii  nnntite  it   would 


;r;iiln;ul\- 


uisai)- 


ndilile   sizxlinii'   sound 


tuiiionr  mass  liecanie   wry   mud 
was  evident    as 


<in 


palpation   the 


1    sotter,    hut    e\-en    w) 


could  Ijo  rolled  beneath    the  fi 
seemed    to    be    that 


somewhat  sau.^a^ire-shaped,    tuiadar    I, 


len     l-ela.\e 


it 


nii'ers. 


I'ieatr 


icial 


piickei 


ni    conse(pience   of    th 


,seciitiv(!  liypertroplu-  of  the  pyl 


'in<,',  with   narrowini,'  of  the  pyl 


>o(ly,    which 

'Xl)laiiatioii 

idcei'   there    was  mucli 


111'  onlv    rational 


)ric  orifice,  and 


P3'lonc  zone 


the  tumonr  ccadd  be  alon.'  explained  on  th. 
iiate  contraction  and  relaxation  of  the  hvpertropl 
uhout  the  pyloru.s  ;  and  with  this  the  evid..nce  ol 


con- 

''"'  pliMiit character  of 

su|)positioii  (,f  an  alter- 


pined  muscular  tissia 


was 


accord,  since  when  the  tu 
cessivelv  firm 


ami 


Hard 


fully  ii 
skin,  it  was  e 

the  hand,  and  with  a  marked  cl 
tions  in   position  and  .size  of  the   tu 
dilatation,  is  often  noticed 


iiKHU'  was  visibh 


'tained  ,m  palpat 


ion 


daxat 


ion   took 


lann'e 


in  tl 


beneath    the 
place  undei- 


le  consistei 


icy. 


lie  \aria- 


iiiour,  with    the  incn 


patient  was  nri-ed  to  hav 


III  pyloric    mas.ses  of   this  el 


-ianuary   20th,    bSHf,.    Since   tl 


e  an  operation,  but 


laracte: 


Would  not  consent. 


in  th 
.     Tl 


le 


ascertained  that  this  patient,  durin-  tl 


the  cai-e  of  J)r.   Bressler,   wl 

stoii 


diovi'    remarks    wer. 
le  summer  of  |,S!)4. 


o    perfol'iiied    successf 


'    written,   I 
came  under 


ly,  usinj,.  Murphy's  button.     At  th..  ..,i.l  of  th..  tl 
••.mvale.scence  was  eHtablishe.l,  neneral  p..rit..nitis  d 


lie  I  lie.  I. 


ully  .yastro-.'nter- 
lir.l  w..(.k.  after 

.'X.'loll. 


ol  wliieii 


Dr.  Bressler 
aii.l  .lescription. 


vei 


■y  kindly  sent  th.'  .siiecinien  to  nie   I 


or  examinati 


.)!! 


The 


specimen  consists  .)f  st.imacl 


intestine  removed 


en  iii(i.sKe.     Attached  to  tl 


1,  except  cardia,    with   th 


e.)ii 


)f 


stomach,  alwut  6  cm.  from  pyl..ru 


le  o 


ri.at.'r  enrvatiire  .)f  th 


(jojiimmi) 


nil. I  with.ait  adl 


he  line  of  attaclnm.nt  is  si 


s,  is  a  portion  of  th 


small  inti.stim 


i.»\v 


st.Muach  a.lmits  th..  in.l..x  fi 
'"•liiiid  the  attachment  of  tl 
il 


ii'sions.     The  artificial  .irifie..  bet 


II  111  frcait ;  iiarr.iw.  cl 


can. 


•  Li'er. 


.  tra 


ween  intestine  and 


iisverse  colon 


e.xil 


11'  st.iniach  and  inte.sti 


'•<!  Murphy's  butt.ai  has  lodj-ed,  and  I 


lie 


passi 
At  tl 


s  (lirec 


I.' 


tly 


splenic 


cm.     The  pyloric  region  of  the  stoniacl 


mscau.sed  a  perforation  2  b 


is  enlarged,  the  ti 


•ansverse 


f 


8 

colon  and  oi.u>ntuni  adherent,  and  tlicre  is  considerable  thickoninj.-  (,r 
peritoneal  tissues  al.out  it.  When  the  duodenum  is  opened, 'l.h, 
thickened  lips  of  the  i)ylorus  ean  he  seen,  and  a  circular  oriHcc;  ahoui 
5  mm.  in  diameter.  From  the  stomach,  the  little  tinj^er  cannot  ]>,■ 
niserted  into  the  rinn-  There  is  a  narrow  channel  throus^h  which  a  Icn  I 
pencil  could  !..•  pas.s..,l.  When  laid  open,  the  thicken.'d  walls  seem  tu 
I le  made  up  of  a  oreyish  connective  ti.ssue,  and  enormous  thickenin.. 

of  the   mu.scularis.     The   wall    measures   in   , place    14   nun.     'I'li' 

mucous  membrane  correspond intr  to  the  thickened  portion  is  in  placs 
pucker.'d,  looks  thin,  and  at  one  jKant,  correspoudin.t;-  to  the  anteri.^r 
wall,  and  about  :i  cm.  from  the  duodenal  orifice,  tliere  is  an  area  i:, 
by  10  nnn.,  which  looks  lik(;  the  door  of  a  healino-  ulcer.  The  wli,.|c 
nm.'^culai-  coat  of  stomach  is  <,n-eatly  hypei-tro})hied. 

A  portion  of  the  pylorus  was  cut  out  from  the  peritoneum  to  tlir 
flooi-  of  the  ulcer,  and  I  am  imlebted  to  Dr.  Blunur  for  sections. 
There  was  nowhere  any  trace  of  carcinoma.  Almost  the  entire  niiiss 
was  made  up  of  enormously  hypertrophied  nuiscularis.  Neai'  the  fln,,r 
of  the  ulcer  a  large  artery  was  cut  acro.ss,  which  showed  a  thickeii,.,] 
muscularis  and  great  proliferation  of  the  sub-eiulotlielial  layer. 


c^uvii 


CHAPTER   VI. 

DISEASES  THE  DIRErT  OR  rXDIllECT  lUNn  T  OF 

IXFErTIOX. 

Hv   WILLIAM!  OSLKR,  ,M.D. 

CERBBRO-SPINAL    MENINGITIS. 
Definition.     A  specific  infections  d 


'■]' 


isciisc,  dcciirriii" 


cliiiractcnzcd    auatomiciillv  hv   ini 


iraiiiciiilv  and 


III 


s|iiiial  conl,  and  ciiuicaiiv  hv  an   e.xcec'diii'd 
"    ■       fcv  '      ■  ~ 


aiiiinatioii    of   tiic   I. rain    and 


syiiiiitoiiis  licina-  fever,  pain  in  tlie  lieail  and   had 
severe  tonus,  delirium  and  eoiiia. 

Etiology.     Tile  iiistorv  of  tlie  disea.se  (hiriim-  tl 
liale  of  tlie  first   i'eeo;:nizeiI  epid: 
the  worlds  of  Hii-seh,  of  St  ilk', 


y  iiTe-nlar  course,    tlie    ciiief 


imisciihir  spasms,  and.  in 


•iiiic  in  Cieneva,  in    Ist 


le  present  centiirv,  from  ll 


("iiil(h 


and  of  Joseiili  ,J 


IS  fnl 


ly  ,i:iven  in 


one:' 


■en  an<l  yoiiiiu-  adults  are  most  siisceptihle  |,i  the  il 


epidemics  adults  have  heeii  chiell 


\m 


H'  ('(piallv  liahle.     Tl 
III   1 S7;!  't 


y  attacked.     Mules  and  ibmal 


isease,  hut  in  some 
I's  appear  to 


le  most  severe  epidemics  have  heeii  in  countrv  district 


le  disea.-^e  was  very  prevalent   in   the  vallev  of  the  ( 


and  the  villa.i^es  and  country"  districts  suffei 
the  cities  of  Ottawa  and  >rontreal. 


'od  much  more 


)ftawa  Ivivor, 


severe 


Iv  tl 


Kill  did 


The  affection   has  1 


eiich  otlu 


Tl 


rokeii  out  <iiniiltaiieoi 


isly  ill    rcujons  tin-  distant   i 


tieconcenlrationof  population,  as  in  lar-c  iiarracl 


rom 


houses,  favors  the  (U'Velopnieiit    of  the  di.<t'a.se 
fourth  decade  the  niii 


and 


Ks  aiiil  woi 


111    I'  ranee  diiriiio'  the 


pitals.     The  outhreaks  h; 


iierous  epidiMiiics  were  almost  confined  to  milit 


jmiij;-,  and  liavo  developed  in  except 


ivo()cciirred   most    fre(|ueiitlv   in   tl 


hiive  laid  irreat  st 


oiitlireal 


ress  on  excessive  i 


(lit 


IKS  have  been  in  towi 


'ptionall 

uoistnre  as  a  facte 


llltlOIIS. 


I 


overt\-  and  ov 


y  severe  weather. 
Tl 
IS  and  villa-vs  with  verv  (h^fecti 


of  hii'nv  liiiiiilies  dwellino-  too-,.t| 


ercrowdiiio-,  with  the  coincident 


iry  lios- 

le    winter  and 

■'iMiie  writers 

le   iiKL-t  serious 

ve  saiiitar\-  con- 


r  ill  small,  impert 


tenements,  favor  the  development  of  tl 


ectiv  V( 


misery  and  sepnilor 
111  dated  houses  or 


prolminvd  marches,  ha 
tiiiit  iiilhicnce. 


le  disease, 


Ovei 


teen  loiind   liy  militarv  siirLreoiis  to  I 


erexertion,  as  in 


ia\i'  an   impor- 


T 


10  disea.-^e  .loos  not   appear  to  he  directiv  coiit 


indei'd,  to  have  tw 


o  case-;   in  the  oni 


lii'loil.- 


It  IS  exceiil 


niivly  attacked.     On  tiie  other  hand,  tl 


11'   lioiise,  and   physicians  and 


niiiv 


loiial, 
's  are 


"f  the  view  that  tl 
CO  to  another. 


lere  IS  Verv  st  roi 


Kvid 


lie   poisim   niav 

"Several  strikin'o'  instances  of  this 


ii;'  evidence  in  favor 


'.'('oliitus  1 


•'"'••'  IS  accumiilatino  in  fi,vor  of  the  view  that  tl 


ransmitted   liy  individuals  from  one 
■e   rejiortcd  hv  Hirscli. 


(leiiio 


iiiv  lui  etiological 


iistrated  in  the  exudate  of 


relation  l.(  the   diseas 


pivseiii  111  themeniiioitissecondarv  to  i 
in  many  instances  of  sporadic  cerehr.. 


the  meniiiocs  in  i 


tie  mierococciis  Ian- 
Its   presenc(.  has  been 


>neniiioiiia,  and  it 


iiaiiy  epidemics.      I;    is  als 


wn  Inis  also  heen  d 


enionstrateil  in  t 


spinal 


le  nieniiioitis  deve 


heen  found  now 

iiieiiinoitis.     The  same  organ- 

'piiiu-  ill  the  course  of 


► 


(r- 


204 


XERVor.s  i>i.si:asI':s  .l\7>  thi.vr  tiieatmkxt. 


flisciisfs  otlicr  tliaii   |mfiinn)iiiii    and   in  llmt   follDwiiiif 


iiijiirv.     Altd^ri'tlii  r, 
scrvatiuiis  of  tlic  |)asi  ten  years  point  to'  the  associalinn 


tile  hactcriolooicai 

of  the  niicrococcus  lanccolatiis  witli  hotl'i  t lie  sporadic  and  tlic  cpidcniic  f 
ot  the  disuasi'.     Otlirr  ornanisnis  liavc  liccn  met  with  in  purulent  nieninL.. 
tiu'stapiiylocfHTUs  jn-ojivncs  aureus,  tlu'  typhoid   haeilhis,  the  cohju  hacfll 
and  other  li'ss  detiniti'  forms. 


Olllli 

■ili«, 


tl 


There  are  insnperahh    diftienhies  in   the  wav  of  a   rational  exiila 


le  conditions  favoriii:^-  t 


le  Lii'ow 


iiieiiiiiiie? 


a 


Tl 


til  and  development  of  tl 


nalmii  ,,| 
u'  ori;anism  in   ih,. 


le  micrococcus  lanceolatus  is  a  normal  occu|)ant  of  the  lioij 


very  considerable  proportion  of  all  individuals,  at  least  20  percent 
inir  to  some  authors. 

The  possibility  of  the  disea>e  heini;-  due  to  an  aiito-infeclion  has  1 


V   II! 


ai'ciii'i 


Lrested    through  the  nasal 


leeii  -ii- 


Flexner  and  iJark 


lossa  li\-  strumpe 


T 


and  throuiih   the   intestine  li 


lere  are  serious  ditHcuIti 


es,  llowever 


in   tl 


acceptinir  such  views  which  otlia'   no  explanation  whatever  of  tl 
prevalence,    or   of  the   remarkable  facts  ipioted    bv  llirsch    in    I 
transmission  from  one  localitv  to  another  bv  a  third  person 
Morbid  Anatomy.     The  patient  inav  die'before  aiiv  " 


le  \Miy  (i|' 

le  cjiiili mi,. 

ivor  (.r  i|. 


nccnrs  in   the   meiiinu'es,  and   then   the  condition 


if  1 


lypera'inia   and  o 


f  a  slioht  s( 


in       iiinatory  exiuhitr 
is  one  ot   an  extreme 


rolls  efliision.      In  well-devel 


i'i'ililc 
i>l)eil    cases  111! 


external   inspection   the   petechia/,  sometimes   herpes,  may  be  noticed  on  th,. 
skin.     On  removiii,:,'  the  skull-cap   the  dura    is  tense,  aiid   its  inner  sinrnc, 
liyiK'iU'inic;  the  sinuses  full  of  tirin  clots.     On  exijosin^  the  cert 
in  .severe  ca.ses  the  eonvolut ions  mav  be  eovereii  comijietelv  witi 


exudate.     Often  t 


i  ciiriix 
cri'iiiiiv 


IS  patcuy,  most    marked,  perhaps,  on  either  side  of  i| 


iiLrittidinal   tissiire  and   in  the  chief  sulci.     Tl 


le  cortical  veins  inav  lie  ill 


tended  and  prominent,  and  the  smaller  ves.-cls  of  the  pia  are  (iee]>ly  eiiLiiiri;v, 
Occasionally  siiperticial   hemorrhau'es  are  seen;  the  exudate  is  upon  tlic  pi 


Iter  ;  the  arachnoid  itself  may  be  opatpie.     The  etfiisiou  is  usual 


at  the  ba.se  of  the  brain  about  the  chiasi 


na  ami   in  the  Svlvian   tissii 


le   plU 

V  auiiiiiliint 


res,  iiikI 


ni; 


ly  cov(>r  completely  the  pons  and  medulla.     The  lesions  are  not   conlimil 


to  the  meninges,  but  the  cerebral  substance  is  also  iiivob,  ed,  and  t 


ilit 


V  a  meiiinuo-eiiceji 


halitis.  Theuray  matter  is  hypera'in 


foci  of  intiltralion  and  of  hemorrhage  may  be  seen.     Absces.ses  of' .(u 
are  occasionally  tiiund.     The  intlaiumatio'n  may  involve  ti 
ba.'^e,  which  are  surrounded  with  the  tibrinoiis  exudate.     Tl 
contain  oiilv  an  increased  amount  of  serum,  1 


lie   pi'iirr" 
ic.  Juicy,  1111.1 

Mr  >i/c 
It    till' 


le  nerve- 


le  veil 


triclr- 

eriim,  hut  in  some  instances  the  ii 


Illation  IS  most  inteiis 


the  velum  and  choroidal  nlexiis 


r 


le  epciiihina 


is  softened,  ecchymosed,  inliltrated   with   and   <'overed    bv   pus,  and   tl 

triciilar  contents  may  be  of  the  same  nature.  In  ea.H's  which  have  l:i>i(d  Inr 
a  long  time  there  may  be  no  longer  any  tibrinoiis  exudates,  but  ilmv  mv 
areas  of  meningeal  thickening,  adJicsions,  and  most  constant  of  all  -ivat  in- 
crease in  the  serous  I'lfusion,  which  may  cause  great  dilatation  of  the  viiiiriclr- 
(hydroc<'plialiisi.  Mveii  in  cases  in  which  <leatli  has  taken  place  ^(l -nnii  a- 
the  fifth  week   the  ventricular  effusion    has   amounted   to  three  piiii-.    Tlic 


spinal 
mon. 


inenniger 


low  tlie  same  lesions 


Th 


Small   heiiiorrliat;-es  ai 


'C    llnl    IlllCdIII 


le  exudate  may  be.  in  verv  acute  cases,  onlv  a    turbid 


UKMC  commonly  a  creamy,  thick  material,  chietlvon  tiie 
cord.     l''reiiiieiitl\-  it  collects  more  pai'ticularlv 


irregular  buk 


111  certain   reuioiis 


iiiLis  on  the  arachnoid 


Tl 


'e  greater  urai 


posterior  p;u'l  ot'llie 
pi'oiliicin^' 


leof 


posterior  .surface  is  due  entirely  to  the  etiect  of  gnivitv.     I 

the  entire  cord  is  imbedded  in  a  thick,  grayish-yellow  iympho-puiiiliii 


exinialiiiii  (in  iln' 
11  sonic  iiistaiici's 


e  cord   mav  siiow  the  same  cliaii 


•  late.     The  substances  of  tli 

brain,  namely,  hemorrhages  and   infiltration  with  I 

of  such  extent  as  to  form  si 


1  I'NIl- 

i'l's  as  ill  till 


eucocvtes,  soiiieliiiu's  tmi 


naif  miliarv  al)scesse,s. 


A[icroscopica 


llv  tl 


iL'  oxa- 


i//;.v7'. 

jiii'v.  Altouctlni, 
t  til  the  iissociiili.in 
the  t'pidciiiic  till  III- 
inilcnt  iiK'iiiiiLiiii-. 
the  coldii  l)iicillii~. 

Il;ll     ('Xplillllltinli    ,,| 

ic  (ii'^iiiiisni  in  ilir 

illlt    of    till'    ImiiU    ill 

I)  |it'r  cent.,  ii(T.,n|. 

'tiiiii  has  liccii  Hi^- 
li  tlic  intcsiiiic  l,v 
vi'f,  ill   the  \Mi\  nf 

T  of  tllC    ('|lii|i  liiic 

•h   ill   favor  (if  ii. 


Minatory  cxiidiur 
an  cxtrcnic  ;;iailc 

('V('Io|km1     ('Mm.-  nil 

he  noticed  mi  ihc 
its  inner  Miiiiiiv 
he  cereltral  cuncx 
\y  witli  a  civiiiiiv 
eitlier  side  nf  t|i',. 
veins  may  he  ilj,. 
:>  (leej)ly  enL:nii;i.,|, 
te  is  iijioii  I  he  |)ia 
'  usually  ahumlaiii 
Ivian  fissure>,  mihI 
are  not  eimliiu.il 

I,  and  the    prnrr" 

I'ra'inie,  '\iury.  mid 
[•esses  of  sonic  >i/(. 
the  ner\r>  at  ilic 
'lie  ventrirlr-  inav 
•taiiees  the  iutlain- 
The  i'|M'iiilviiia 
|)us,  ami  ilir  vni- 
eh  have  la>ie(l  tnr 
tes,  hut  llierr  aiv 
It  of'  all   -nal  in- 

111  of  the  \rlllric|r> 

1  place  ,~n  -non  a- 
three  piiiN.  Tile 
es  are  im'I  iiiioihi- 
iirliid  M'i'uni,  Imt 
isterior  pari  of  the 
■eu'ioiis,  pl'oiliiciii:; 
exudation  en  tliu 
In  sonic  iii>laiiiv> 

pllo-|H|l  illrlll  r.VH- 

•lianu'i's  as  in  the 
es,  soiiicliiiH's  tiii'i 
•opieally  the  cxii- 


% 


% 


isri:<rivh:  /^/.s/.m.s/x 


205 


,l:,fr   consists   o      I.nlv.Hlcl,,,r    l,.,.,.o,.vt,.s.    lvMI|.l,ni,|     ,.,.||s     Imp..,.   ,.,.|N  uiti, 

v:MM.,h.r  nn..lH,an.l  .v..,,   ,...|1.  lar^..,-  s.ili,  ui.i. sun..     ,h    .J       , 

nuiii.-nms,  and    cvni    tlics.-    cuntain  otluT    Icncocvtc-  .m„I    .'..,1    1,1  i 

»illiin  tli(<n..     (Floxnor  ami    Harkcr  )     Th..     .  ,:,•  1'            i  '■''"" 

..ually  1... -Innonstrato-I  i„  the  o      la  ..       '  „•    '        Z''  n     i:"'";  """  ""'' 


\  M'Vcrc  cases  there   niav  he 


h,morrha;r..s  on  the  sen.„s  ,nen,hranes.      The  h,n^.  oUen  show  eha ....,- 

rinlis,  nitens..  hypenenua  an.    ...,l.,na,  an.l  s,..n<.tinies  l.,hnhir   h..<  (V...,;,,,      • 
Umi' |.iu.m„oM,a.     A''''>'' -nHatmnati.a.  ..f  th..  ph.nra  an.l  ..f  tl...  peri.S 
h:,>  .ISO  he.  ,  t..n...l:    en,lo,.ar,lms  is  ra.-e;    ..olitis  n,av  1...    ,.nL..nt        1    .. 
>pl....n  nsna  Iv  varu.s  ,n  s,/..  a.r.a.lin,.    t.,  th..    p,.,.!.,,! 'a,   wh,.|,  ,|.  nh       s 
ocrm"....l.     It  naiv  s.)in(.tini..:;  h(.  H|.,..,t|y  ..nl.M'..-eil  ".niina> 

Symptomatology.  A  s.a....of  in,.uhation  with  |.ro,!,„M,ai  svn.pton.s  i<  rare 
Le^sol  a|>,...t,t..,  .nalais..,  h,.a.la..h..,  ,,a.n  in  th..  Ihnhs  o,.,.nr  in  a  tew  .•'  ■  " 
lh.;oMs..t,as  a  rule,  as  ,n  pnentnonia,  is  ahrnpt.  an.l  the  i.ati..nt.  witlani 
m.,nn  nary  sympt.mis  .,t  any  tn.unent,  is  sei....l  with  a  ..hi!  .,r  with  v 
..■a.lM..h...  v..nn  tnjr,  an.l  tever.  F..w  .lisor.iers  ,,r..s..nt  so  vari..,l  sv  t, - 
„Mlolo;,y   an.    the  .■as..s  ar..  perhaps  iu.st  .l..s..rilH..l  in  .ronps  ..j.ara.ie'       1 


Itv  sin'CKH  iciiturcr- 


.  Ialun,.n,l  Juni,  N.,  acute  .l,sease-ch.,lera  s..ar....|v  .■x..ept,..l-n>av 
1<  11  with  sn.'h  rapnhty  as  ,.er<.hr.,.spinal  «,enin,.itis.  Cas..;.  are  .,  1  r.'cn  n 
wu..h.l..a.h  occnrre.    after  an   illn..s>  of  t..n   hours,  or  ev,.u  ..f   i v  .       , 

las  type  .s  seen   w.th  yar.ahle  fre,|Uen..y  in   .lirt;.r..nt  ,.pi.l..n,i..s.     I        ho 
>•.;....>.    .a.e  stu.he.     i.y  !•  leNn..r  an.l    I'.arker  ten   patients '.li,..l  witlm.  tat  ' 
,.,,■!,    h.n.rs  after    lu-  app..aran,...  ..fth,.  sy„,pt.ans.'  Th..  .,ns..t  is  ahrupt      if], 
;•  vinl'M.  ..Inll,  an.l  without  tin-  s  „iu.st  pretnoniti.m  the  pati,.nt  n,av  1   .  ...i  , 
Mh  a^.au/,n;,  lu.u  ache,  vonnfn;,,  hij^h  fbver.  a.-tive  .I'lirinni,  sue....e.l.     h 
,  .,,   ,l..pr..ss,.a,  ..f  the  y.tal  funetu.ns,  jrra.lnal  sonn,.,l..n.....  >on;..,in,..s  111 
.1   n,,.  ,ty..f  the  nHis,.les   or  even   o,.u..ral   ..onvnlsions.      I),.ath   niav    .'e  r 
l"'t"'r    1...  .K.v..lopnient  .,f  p..t....i,ia.  .,n  the  skin,  hut  in  ..as..s       !,•      •,      , 
""Mv  than  tw,.nty-f.,ur  hours  lu.rp..s  an.l  ..,...hvu,.,s..s  a.v  ahu.,      i   v  ri  .1  Iv 
.-s..nl.        la.  fever  i„   this  s.M.all...l  ap.,pi....tic  tvp..  is  no  . L  ^hI   h 

'Muaayot  the  .'a.es  ,  has  luru  .,uite  naMlerat...' 102=  an.l  lo;^  ;  ,le  ule 
'nav  h,.  rapi.l  a.j.  feehle,  hnt  instan..es  are  ,a.  re..or.l  in  whi..],  i  \l  1  '  ,n 
>lnw,  iMlhnirt.DOor  (iO  in  th..  mini    ...  *^^" 

•J.   Onlnmnj  form.     (  oinin.mly  witlmut  anv  pr.).lonml  sv Um<  the  .li< 

.,>..ses,nwm.s.w..n...hill,hea.la..h...an.lv..nn'ti,.;r.  Thelu.i.la  ...  „i 
..\.r.  an.l  a..,.o,npau...,l  with  -irat  sensitiven,.ss  t..  lid.t  an.l  t.,  n.ii  e<  ■  • 
l-i:tlHs..  over  the  entire  hea.l,  or  !o..alix...,l    chi..tly   to    the  ,.c,.i,,,it    .a-    ti? 


tul' 

lH't 


"'-•■   .T^  i--;'^  the  ,n..st  istaut  .i.atu;:of' iia^Ms;;:;.  ''''Vl  e  t^ 

a<mv  ns..s  rapnlly  an.l   may  r..a..h    lO-V  .a'  1(.-|°,  sonu.tinu.s  hiulu.r        t 

a>,.    ally  even   in   severe  cases  the  pyr..xia   is  n.>t  at  the  „uts,.t  .n- .h  r 

ll"''-u,s..ot  a   h.i:h    ora.ie.     The  pulse  is  full   ami  >trou..- •   lat..r  irr...     1   ," 

ai:     u   ..n  >yn,p,.,ins  of  .lepressi.m  .urnr  fLehle  an.l  ra,:i,  .         u  ,   -re      ' 

"   '''li  l:as  „..  hx,.,ltype,.  .K.sn..t  really  lu.ar  anv  relation  t.    th,.  s..v,.ri  n  ,  f  tS 

;r  symptonis.     \  ,an.tin,^  whi..h  o,.cnrs  ..aViv.  mav  .-..as.,  with  n     we„    ■ 

hours..,,,  in  ex.;cpt. .1  ..as..s  r,.,.nrs  thnai^hout- the  ...airs..  of  1      "£. 

^.        of  tho  hack    a..c.aupanH..l  with  aehin,-,   whidi  often   ..xt..n.ls 
in    -s      A.  tie  .hsease  i.r..^ivss..s,  usually  fr..in  the  s..,.on.l  t..  the 
'i  'l.i.v.  ilu    St  ttm.ss  he,...nu.s  ima'c   mark..,!,  ami  ther..  mav  1...  rio-i.litv  .i■ 
,;; -- -  m  jhe  Im.-k  an,l  u....k,  th..  la^ 

'.     '  |i>Ih.).ai.,s  is  i,.,t  .■..mmon.   hut  .a-thot,a,.,s,  in  which  the  trunk  i< 

.-"i..,.l  n,„htN  ami  stiHiicss  was  su,.h  that  the  l.o.ly  ,.,u.|.|  h,  ,„„v..,l  like  a 


if 


a 
I 


i 


h 


•201] 


i\/:iiyoi's  dis]':asi-:s  am>  tiieiu  teeatmi-:xt. 


statue,     rniliitfral  spasm  (if  tlic  liack  niiisclcs,  Icadiii^r  I"  |ilciir(.stliut 
rare.     Kxcciil  in  early  cliilillKiipd  ami  a  slmrt  t'        ' 


Ollll- 


viilsions  are  nut  coimiikiii. 


T 


liie  heliife  death  general  i  mi 
■emiiror  elunie  >))asms  may  lie  present.     S| 


i)t  tlu'  muscles  111'  tlie  face  may  also  eeenr.  Lesions  (if  the  nerves  ut  the  li:!-, 
may  cause  paralysis  of  the  muscles  supplied  hy  the  third,  ineijuality  of  ih, 
pujiils,  nysta^.-'ums,  deafness,  and  disturliances  of  the  sense  of  smell,  i^joliii,.. 
respirations,  and   ( 'heyne-Stokes   lireathiiii,'-  are  met  with   in  some  insian, ,"' 

Intra-ocular  ehanui's   are  com i,  partiddarly    passive    couLicstion    of   ili, 

retinal  veins  and  optic  neuritis.  I )i.-iurlianee' (.,' sensation  is  common,  |,;||-. 
ticiilarlv  hypera'sthesia  of  the  skin,  and  the  patient  mav  crv  out  wImi, 
attemiitin^n- to  move  the  trunk  or  limlis.  In  part  this  mav  he  due  to  li\|„|. 
a'sthesia,  and  sometimes  to  the  tension  spasm  in  the  nuiscles.  It  mavlic\,n 
marked  in  the  leas,  and  the  sliiihlest  movement  may  lie  sufilcient,  even  in':, 
patient  in  a  profound  stupor,  to  cause  reflex  spasms. 

Thecutaiieous  features  of  the  disease  are  important.  The  petechial  r.i.ji 
which  hasi-iven  the  name  "spotted  fever"  to  the  atlectiou,  is  very  varinli],' 
Stille  states  that  they  were  pre.-*ont  in  only  .'!7  of  !t«ea.<es  in  the  ri'iiladelpliiu 
Hospital.  With  the  ecehymoses  there  'may  he  roseola  and  ervlheiii,i,  ,,r 
these  latter  may  occur  alone.  The  distriliuti'ou  of  the  petechia'  may  he  >viii. 
metrical.  _  In  the  epidenuc  at  r.oiiaconinj:,  studied  hy  I'^lexner  anil  IJaiku, 
the  jietechial  eruption  was  comparatively  rare,  hut  an  indistinct  pnr|,li>|i 
mottlim;- over  the  surface  of  the  liody  was"  more  common.  Herpes  is  piiliMi,, 
iiiore  freijiK'nt  in  this  than  in  any"  other  disease.  J t  is  seen  first  upon  Ih,. 
face,  either  on  the  nose  or  li|is,  iuit"  often  extends,  and  is  svunaetricid  in  ii- 
(li.strilnition.  Urticarial  forms  of  erytheuui,  pemphiuiis,  and  in  a  few  in- 
stances  oanirrene  of  the  skin  have  lieen  descrihed. 

As  alreadv  nuMitioned,  vomitinii'  is  an  early  and  a  prominent  s\  iiipimii. 
The  tonpie  in  protracted  ca.<es  is  dry  and  (Mivered  with  .<or(les.  Laciuiiir 
ton.sillitis  sometimes  occurs.  Difficulty  in  swallowinir  mav  he  due  eitlur  tn 
the  extreme  retraction  of  the  neck  or' to  disturluMl  innerv"ation.  Diarrlma 
w  not  eommon,  hut  in  four  of  tlie  Lomieoninn-  cases  alreadv  referred  In  tlicio 
was  well-marked  dysentery.  Theali(hiinen  is  somewhat  retracted,  dauinliiv 
ha.s  heeu  met  with  in  a  few  instances.  The  spleen  is  sometimes  enlariicd,  lnit. 
from  the  vary in,:i-  statements  made  with  reference  to  it,  it  evideiitiv  i>  not  ;i 
eommon  feature.  Of  respiratory  .symptoms  disturhed  rhvthm  in  lirealliiiii' 
is  comnuin,  particularly  toward  the  elo.-^e,  and  the  respirations  may  he  of  tin" 
Cheyue-Stokes  type.  Mpistaxis  is  a  very  fre(|ueiit  feature  in  som('  e|ii(|riiii(s, 
Bronchitis,  lironcho-pncumonia,  and  pneumonia  occasionallv  occur,  ;uhI  in 
the  protracted  cases  there  is  much  hypostatic  coue-estion  at  tlie  lia.-^es. 

In  the  severer  cases  the  urine  is  alhuminoiis  and  mav  show  the  prc'^ciicc  nf 
hyaline  ami  <iranular  casts.  Thosphates  are  often  in  "exees.s,  and  hin,,,!  mav 
l)e  jiresent  in  the  severer  ea,<es.     .Marked  polyuria  has  lieeii  noted,  and  it  lia- 

soinetimes  persisted  for  years,     (ilycosuria   mav  also  occur.     The  hi I  cnii- 

dition  was  carefully  studied  liy  Flexnei'  and  li'arker,  who  tiiund  iiiaikcl  Idi- 
cocyt.isis  in  all  the  ca.-ics.  Neither  the  red  corpuscles  nor  the  li;riiinnli,|,iii 
showed  any  ,«pecial  chanirc-^. 

The  course  of  the  disea.s'  is  extremely  varialile.  More  than  onc-halldiilii' 
deaths  occur  within  the  firsi  five  days."  Improvciment  is  indicated  In  a  fiill 
in  ifie  fever,  lessening-  of  the  spasm,  and  a  return  of  consciousness.  Ciiiiva- 
lescence  may  he  extremely  tedious,  and  after  tlu'  acute  symptc;ii>  have  >iili- 
sided  may  lie  inti'irupted  hy  the  complications  and  .^ecpiehe  to  he  iiieiitidiiiil 
shortlv. 


.S.   .1/ 


I /nil--'  /'(; 


(<0  Ahortii'i-  fi///i:     TIr.  attack   mav  set   in  aciitfly 


with    hiji-h   fevei',  severe    headache,  ]ihotoplioliia,  hut   in  a  few  da\  -  all  tin- 
symptoms  suhside  and  rapid  eonvale.<eenee  is  e.^tahlished.     Striimiiell  di^iiii- 


Mi:.\T. 


ilciirustliiit 


OIK  IS    i« 


(nil- 


(Icalli  ut'iici'iil 
lu'  prcsi'iit.  Sjiji-M 
'  nerves  at  tlie  \k\-v 
1,  iiKMHiiility  (if  ill, 
of  smell.     Si^liiii- 

in  some  instiiiiio. 

ciinui'.-tion   (if  I  III 
i>n  is  ciiinniiii 
iiiiy  ciy  (lilt   \\\ 
:  !)('  (hie  t(i   I 


|iai'- 


i\  iii'i- 


III! 


It  may  lie 
icieiit,  e\ci 


I  III  ;i 


The  |)eteeliial  rash. 
II,  is  verv  varialilc, 
in  the  I'l'iiiad 


I'l   ervll 


l|ilil;i 
leliia,  ii|' 
ecliia'  may  hr  m  m. 
exiier  and  IJaikn. 
imlistiiict  |iiii|ili>|i 
Herpes  is  |icilia|is 

lli'lll  tlio 


seen  first  i 


symiiielricai  iii  m 
and    in  a  iiw  in- 

(iminent  syiii|iiiiiii. 
sonles.  l,ariiiiiir 
ly  1)0  (hie  eillicr  to 
I'ation.  Diarrliua 
Iv  ref'erri'd  in  ihciv 


raeted 


llllllllCO 


nies  enlarucil,  Imt, 
evidently  i<  imt  a 
■thiu  in  lircatliiiiL' 
(ins  may  he  nf  tlii' 
in  sdiuc  e|ii(|iiiiics. 
liiv  (icciir,  ami  in 
tl 
i\v  tl 


le  Dase.' 


le  iirc^riicc  lit 


ss,  and  111 I  iiiav 

1  noted,  and  il  iuh 

The  liliiiiil  cull- 

(Uiiid  marked  icii- 

r  the  ha'iiiii;;iiiliiii 


laii  oiie-ha 
ndicatid 


iii|it 
e  to  I 


If  of  the 
IV  a  full 

(  'iillVll- 


(■ni>  nave  .-iin 
le  iiifiitiiiiii'i 


liV   set    !:i  iinitcly 
few  (la\  -  all  llii.-r 


Striiii 


■11  distill- 


» 


isiF.iriVK  I) IS/: ASKS. 


2(17 


^'iiislifi*   iM'tWci'ii    the  iiliiirli\('   forrii,  set 


I,  aiiilmliint    cn.-c.-,    wliidi   Imvc    liccii  (Icsciilicd 


liiiir  in  with   lh'i'ih   inicii-iiN ,  mul 


I'liiiiiilaiii  III 


III! 
Ill       Wllicll      III!'      IIMliclll- 


illHl 


si  ill! 


IflKlilClIC,    IlilllM.ll,    llll|>ll'ilMIIII    SCllSillidllS   ill    till'     llllck     illlll 


li's«  III  tllc  lice 


Tl 


llllli> 


ll'Vi'i'.     >ii('li  I'li.^cs  iMiiih 


I  mil 


iciv  iiiav  lie  III)  initial  v itiiiL;-  ami  vcrv  sliyht 


y,  III  I'fiilitv,  III'  ic(M);:iii/,c(l 


if  I  he  (lisca.-c  (jiirin;;-  the  iirfvalciicc  (if  an  cpidci 


iliii'  \i>  till' 


|iii|snli 


//)   liilrniiilti  iif  hi/ir.      In    this   form   the  fever  is  of 


iis-iiniiiij.'  sometimi's  a  (|miti(lian,  sometimes  a  tert 


an   inlei'inittenl  type, 


laii   chafacter,  ami  in  tin 


liTvals  of  the   fever  there  may  lie  almost  eomphte   freedom  fru'iii  the  ot  her 


plonis  of  the  disease.     This  is  a   form  upon  whiel 


>\iii 


tdriiiation. 


ue  reipiire  further  in- 


in 


H'ninlr  hi/i,.     'I'he  attack  may  he  pioiraeled  for  two  orthree  i tlis 

'.(•ii  extend  to  SIX    months,  ami  may  lead  lo  the  most  intense  iiiara>iiiiis 


There  are  reeiirreiiees  of  the  fever;   thus  lleiii 


)ner  ui\es  an  ni>taiieenf  a  iai 


iL'cil  seven  years,  who   had  repeated   reeiirreiiees  from   the  end  of  I'eiirii 
nil  the  end  of  dmie,  and,  tiioiiiih  \\(irii   to  a  .-keielnn,  he  mail 


i'eciiver\'. 


naile  a  enlllpl.-le 


lerieardiiis  are  rare. 


CiiMi'i.lcATloNs  AM)  S|.:(;tKi,.K.      Kiiiioeardilis  ami 
I'lieiiinonia,  Inhar  or  lolailar,  is  a  fre(|iient  eomplieatioi'i  in  some  eiiiih.nill'- 
Tlie  pereeiitap  of  ca.ses  is,  however,  very  variaide  in  dilli'ivnl  epiileiiiii>;  in 

- I'll  niaiority  of  the  eases  iaive  jncseiited   this  ei.mplieation.      It    mav  he 

pivseiit  only  toward  the  close  of  an   epidemic.      Parotitis  has  lieen  descri'lied, 
mill  occuired  in  a  nnmlier  of  ca.ses  in  the  Lona 


coiiino'  epKJeiiiK 


V  ivniarkalile  eomidication  is  the  arthritis  first  descrihed  hy  .James  Jack- 

n^iderahly  in  ditll'rent  epidemics.     In 


.■^oii,  Sr.,  the  miinlier  of  ea.ses  varv 


ma:  •'•> 


lie  Ijiinaconin 


LT  e])i(lemic  twenty  per  cent,  of  the  .severe 


itH'ctiiiiis,  the  knees,  elbows,  wrists,  and  aiikl 


case; 


had 


nine  cases  ill  which,  had    it    not 
iiiciiliiiiitis,  the  disease  would  iiav 


ipciii;;  involved.      Ther 


lieeii  I'or  the    initial  svmptonis  indi 


joint 
e  were 
catiiii'-  a 


e  heeii  iliaa'iiosed  acute  rlieiimatisi 


K 


ei'- 
meiiinaitis 


has  described  a  symptom  which  he  thinks  is  iiatlionnomonic  of . 

ill  tliirt(rn  eases  he  oli.seryed  a  iieciiliar  fiexion-coiitractiire  ( i)eii::vd<onrr'ak 

le  |»atieiit  was  in 
not  be 


tin)  iif  the  knee-joints,  which  could  not  be  reduced  when  tl 

the  sitting  position.      In  attemptiiii.'-  to  extend   the  knee,  the  lei;'  could 
striiii;hteiied   farther  than    a   point    where   it    made 
with  the  thiuh,  althoiiuli  when   Ivinu'  or  standini.'-  tl 


ler  than   a  point    where  it    made  an  an.ule  of  about  1;;.)° 


Irlely  absent.      If  llu'  patient  lay  on  his  ,>ide  with  the  thiiilis  d 
.symptom  wa,s  .still  present.     It  liiis  been  claimed  that  tl 


lis  contracture  was  eom- 


ra 


may  he  ,<een  in  manvother  conditions  (ol 


wii  up  the 
di 


(1  auc,  chronic  al 


le  same  plieiioniena 


iholis 


111,  etc."),  but 


vcriiiir  a.s,serts  that  he  has  exainined  thousands  of  individuals  with  particul 
vfciviiee  to  this  point,  and  has  never  fiiiiid   this  i traili 


ot  nieiiliiLi-itis 


!■('  except  111  euso.s 


Tl 


most  important  seipiehe  are  those  aHectinj^  tlie 


titis  may  develop  with  ulceration  ;   less  often   iritis.     The  d 


pecial  sense? 


>era- 


tis  may  he  followed  by  atrophy  and   bliiidi 


IC; 


'erioiis  auditorv  le- 


oiilih'  optic  iieiiri- 


loiis  are 


Mill  more  common.  Deafness  may  follow  inflanimatioii  of  the  labvriiith,  ami 
III  rliililreii  this  not  iufreiinently  h^ads  to  the  condition  of  deaf-mu'tism.  It  is 
mtcivsiniu'  to  note  that  in  the  (ieaf-nmte  institution  at  lianiberg,  of  forty-two 
I'liliils  111  |,S74,  all  had  lieeome  deaf  luntes  from  epidemic  meiiiii"itis"{  von 
/iciiissen). 

Mcntiil  feebleness  and  aphasia  have  occasionallv  followed  the  disorder 
lltailache  may  persist  for  mouths  or  years  after  an  attack.  \<m  Zieins.s,.n 
nirai.i-  chronic   liydroeephalus  a.s  a   freipient  seipiehe,  the  svniptoms  beini; 

|)iiroxysiiis  of  .severe  headache,  ])aiiis  in  the  neck  and  extreiiiities,  vomitim'' 
l"s>  n(  ciiuseioiisiies.s,  eouvulsions,  and  involuntarv  dischariies  of  feces  and 
iiiiiH'.       Paralysis  of  .some  of  the  cranial  iierve.s  liiav  jiersist.     (Occasionallv 


) 


I 


I 


m 


208  .\ /■:/!]■<> IS  />/.s7.;,i.s7vW  .i.\/)  v///;//-  Tiii:.\nn:.\r. 

.(in-Js,-.m.lv.is..mlwa.,m.  ur, sin.uUU.  ,\u.   ,„   n,ul„,,|..  „..„,„; 

Diagnosis,     Duiinir  ..„  ,.|,i,|,.„M..  tl,..  ,v..u;,„i,i f  ,1...  ,lis,,w.  i-  ...mv    ,„ 

"  '■'''■^'•"1" "I   111''  MiinniMloii-  iv.Ms  is  riuw  -,,  ,.|,,,r  tl.i.i  il,  v    I      "  ■  '  "" 

rase  iinist  |„.  ivc.-iii/.,..!  fn)ni  ixninuKui.      1 1,,  ,|,. 

1.     rnhlh,  ntth,    Arnh,  I  nfrrlj,,,,.-   IH.,„.,..      Tll('<r  illV  V.TV  lil,.lv  t      , 

;;;■'■'•;     '>l '-',''•-'••  l-^i-'-'i-^  wi.l,  .aark.-l  -rn.l.n  In         .',,::      :' 

known  at  \,m  tl.m-  instan.vs  i„  uhirl,  ,|..  .lia.nosi,Juas  n    ,  .     .f  ,..      i   ' 
^p.nal  f..vn-.  I.nt  |.us,.,M„rl..,M  tl...  I..sio„s  wnv  thus..  „f  tv,.h  .y         ,  j     " 

iMn„Mp.s  ,,ns,.„t,.,|  „„ly  ...Ntr,.,,,..  ......uvslin,,.     Th.  n.v...  ,  r     '     ,   .    ,  " 

M        V.      I  ""■'""^■'■"1  ^vnipt......  may  l,.a.l  to  a  .vvisi f  .liM.., 

.Mai.N  .  (   tl,,..,.  ,.a>..s.  iml..s,s  an  autopsy  is  s,.,.nr,.,l,  ;,„  j,,,.,  ,|„.  ,n„rt.,|  u       I 
as  ,.,.r..|.r„-sp,nal    t  .v,.r.     S,  als,.   in    iypluis   »i.v,.r:,l„.    I„.a  L'        1        • 

.' •!".-•  l'VjM'ra.stl„.sia,  an.l  tl...  ,.n.s,.n,.,.  of  n,s,.„la  an.l  , ,',.  !|   .,'.      ' 

"""i  '""^••:,'''"  I"''''."!!'!''"...'  in  .|!,ui„.  In  ,...,.,ain  .  f  1,  slv  ..,•,' 
smallp-.x  t  ...  a,on,.n.,.  |„.a,|a,.|.,.  an.l  ,1...  ,,..„„.|.ial  .-asl.  n  a  '.„  ^ 
'  m^nos.s  .,t  ,...n.|,n.-spinai  n,..ninjritis.  A  tou,-v,.a.-ol,l  .'  I  „  . 
>.;IW..ny   with    t,.v(..-,  pains  in   tl...   I.a.'k  an.l    I,,:,,,!    ..,,1   „.      i..       ''", 


1 


K'k   an, I    ilea. I,  an.l   .mi    tl.,.  >,•,.,, 


■Ill', 
<y  ;i 

til. 
ill 


tl.inl  .lav  p,.t,...l.i.  apl...an.,l  o.r  tl..:  sU..!  T  .."'  ^  Z  ^  ^ ;, 
h.nA  an.l  mark...!  ,•  ,i,|ity  „f  ,|„.  Mn.l.s.  ( •..n.|.,.„.spina  ,.  ■  ,  '  ';  '" 
m  M,.n  ,.,.  an  ..  ,,„.,.,  an.l  l...,|.  „,..  p,,,si..ian  nn.l,.  wl.^'ir '  I  ."[  M 
u.i.,  an.l  '>  ..l>.  I  .  Il.>uai..l,  wla.sawit  ni  (•onsultati..n.  au-m..|  that  tli..«va 

"■■.■m-,v,l,  a...l  ll„.  ,.hi ,,|  ,  „  ,|„:  Ki   '  .  '  ,  ,  "•  ''»■''""""'■'■ 

,.i  .l;;f  :lt'i^: ..' 'i;;:';;^;;:::i;::,i!s;:-,;^„-;;";r^  - '-''- 

Ot/,rr  /■orws  „,     ]fnnn;,>tU.      I,  i.s  t..  I„.  r(.nu.n.lK..v.|  "tliat  ....ILunv,  liii-  unv 
-.■ur  ...  ..p,.l..n.n.  i.a-n..      In  tl...  n;,..a..kal.l,.  ..n,l,..,.ak  wl.i..|.'.,.';.,  .'n  ^M 

alH.iit  lu.tan.l,  \  m...,nt,  an.l  w|„..h   is  .l..s..ril.,.,|  l.v  Cav.rlv   .,(' tl.ii   ,1„ 
n-any  ot  ,1...  ,.as,.s  w,.v  .h.,.,.),,  „  ,i,,,  „  1,,  ..,.r..|.,-;,-spinai  t- !  -.  "' 

.    {'n   h>/>rrn,/„Hs.       I,,,-,,  il...  i„si.li.,ns  „„sot  an.l  , • ,'  pr„t,.a,.t,.,|  ,n„i-,   uv 

;.n|-,an,j.,,,,,,s^an,l.as_tl...,,,,.nin^..s  of  tin nl   a.'    ■.!!,   .Ilh  n   i:;!';,;:;. 


Tllr  -kill 


l-.«k.[<'li,.  an.l  .•|o„j|,y  an.l  r..t.-a..ti..n  ,.f  tl.,.  h,.a.l  aiv  s,.|.I.„m  s,,,, 
miptionsaiv  also   la.v   in  tnlK..r,.l..ns  n...nin.i,is.  an.l  tl„.  pr,.s..n, 
c-l.a;an,    l...,.p,.s,sa,,a,n.t    .1,,.  t,il,..n.„|„„s  fl,,.,,,.     On   tli,.  oil,,.,. V,,,,!   i,„.,i 

li::^:  t  o?'.dr  r'  rr'"^  '--pi^^-.'!  =.pi.asia  an.;..,;;':.;.,;;;:;;, :: 

in  po  tant  of  all.  t    ..  .l,.|....nnnati..n  of  lo.'al  tnl„.m.lons,lis,.asi.  in  oil,,,.,,,,,.!- 
I> )  Pu.  ,nn,uiir  Mn,nHj,lis.      As  tl.c  n„.inl.,.an,.s  „f  tl.,.  la^ain  •„•,.  'hi  (       i-' 

;t;:;i;;;';;:rT''""'''^v^*""'''?'''^-^' :'•''■'■'••'''• ''-^^ 

sp.iM„    l.nt  not  ,.ft,.n  -,.,,,t  n.t,.a..t,.,n  ..f  tl...  n,us..l..s„f  il...  .....'k  .„■  I,i,  k     In 

Ii: ;;,::,.;'''';;;;;.;!',:;  .;;,;;'"'';'f''- '"' ;'"  "r""^''^"  ^' '"'•  ■■•■ 


wlii,.|i  a  lar;:,.  n.aioritv  .,f  tl 


').    ( 'crtiilii  til 


10  ,'as('s 


vuisi.ins,  riai.litvan 


ii.nc  conihliuiiy,  i)arti..nla|.|v  iifa.. 


AVLTc  (•,)nipli,.at,..l  l.v  pi 


'o->p..,al  iiii'iiiniiiii-  ill 


i.'Uiiinnin. 


m.a,  an.l : 


iia,  n.av  li,.  ass.if.iMi.d  with  .■mi- 


initiial,.  m  son. 


,.  .I,.;;r(.t.  c(_.rc.l)nK-])iiial  i.ifi 


r'.i//;.v/'. 

I"   iiiiilli|ilc  riciini;, 

'  iliscasf  in  cusv.  Mini 
at  llicy,  tint,  aiv  uni 
ly  arise  ill  tlu.  s|m,|;|. 
iK'i'c  (it'lcii  (liayih.v'l 
t  rii"pi<,.||.     'I'll,  ,|i,. 

cry  iiivcly  Id  |,i'i  ,,,||, 

true  (•('rcl)i'(i-.|,iii;,| 

iMiiiCotatidiis  (I,  |i|.. 

i'lit.\    "f   tile  liili-rl,. 

'•'  pi<'liin'.  I  |,;n, 
s  made  (.('  cci,  III-,,. 
'Inpi<l  fever,  ;iii,|  III,, 
I'ctil'nw.  s|„,|.  ,||, 
S  iiiitl   the  yTiidiiiil 

vision  nf  ili;|w||.  ,i, 

'III'  iiinrtaiii\  I, ill, 
'""lilclle,  liilcka.li,. 
iK'teeliia'  may  liiin 
(.  severer  ty|iis  ,,(' 
li  may  load'  i.,  t|„ 

I'liild    lieciiiii  ■  il 
i>ii    tile  seciiiiij  I.I 

retnietidii  nf  ill, 
nieiiiiiLMlis  isi-ini 
io.se  care  thr  i|iil,| 
^(■('(1  tliat  liii'  -Miij,. 
it'niis  lieiiiiirr|ii|M,„ 
't'liic,  laeiiialriiicM, 
|"ist.||i,,i'|(.i||  iliciv 
a.iiic  skill  |i;i|iii|i, 
lll|"iX    \v:l«    iiiili;i|i- 

:  (if  it. 

|iniiniiiyelili>  iikiv 
1  (icciirrcd  ill  l^'.l) 
rlv,  ut'  tliai   iiiuii, 

I  fever. 

itl'aete(|  cnlii-.r  ;liv 
Hit    ufteil    allirlid. 

II  seen.     Tlir -kill 

liresellcr    nf   jirt,.. 

tilller  iiaiiil.  Iiii-il 
Kirecdiiiliiiiii,  ;ilii|, 
'il-seili  (illiiTiiiiil-, 
nil!  are  cliirtlv  in- 
ti'eiiiiir  ••iimI  iiintiir 
leck  <ir  li.irk.  In 
'r   tile    |ilillcliiiilli;l 

tis  a  >(i|nriiiT  III' 
iiai  iii('iiiii;;iii-  ill 
elinmni:!. 
-iieialcd  w  illi  cnil- 
lini->niiial  lijcllill- 


( 


1 


iXFiyrivK  nisi:As/:s. 


209 


.ins  I  hcabsnuv  ul  frv,.,-  ainl  tl,..  coiHliii,,,,-  ,n„l,.r  whiH.  ihr  >v,„|,l,u„< 
=n'-.j>''-l  ...  ura.ima.  tlu.  |„v.,.,„v  „f  alhnmin  an,l  ,uh,.-.,,M,<  in  ,1,..  nrin.. 
^liiiuM  make  tiic  (liatiitosis  dear. 

Prognosis      Th..  .nmlality  has  nm-oW  in  various  ..|,i,l,.,„irs  tV ■'(.  „,  T.", 

|„.r  ,vnt       ll.ix.h  statestluu  ot    l.-,,.;;;2  ,.as..s  ;!7  pcT  ......1.  Uir.l.      In  ..InMrn, 

th..  .Irath-rao  ,s  n.^hcr  than  n,  a.lults.  Cases  ni,h  .hvp  ,.„n,a,  rei-eate,!  eon- 
vul-mns.  a.  .1  lugh  tever  rarely  re...ver.  In  tl,e  ..hronie  turn.,  ev.  n  aft,.r  the 
.vNipmnis  have  persisted  for  months  an,l  tl,..,v  i,  ,,x, ,,,„„.  ,,,,„i„„.  ^j,,  ,  , 
li:b-lur''s,  |ierleet  I'ecuvery  mav  oeenr. 

Treatment.     Consi.h.rin-  tlie  liv,,nent  assoeiati f  ih,.  ,lisea<..  w-ii,  lihhv 

sinro.Mahn-s  an  important  prophyhuMJe  measure  is  the  thor.,.i..|.  .h.uKi Z,!' 

lowii-  and  vilhi,u-es  Ml  localities  liahl,.  to  the  disorder  ~  ' 

A.  in  other  sp...iti,.t;.ver<  eaivtul  ,n.rsi„.  and  n.edi,,^  are  the  n.w,  inmor- 
l:ni  elements  m  the  reatnieiit.  11,,.  i,,,,,,,  should  he  kept  dark  and  tmr- 
eudily  vntilated  I  he  diet  should  eon.isi  of  milk  and  slroie.-  hroih-  Manx- 
eases  are  very  .lilheult  to  t^ed,  and   it  may  he  i„.,.e>sarv  to   use  the  ^tonnef, 


tuhf.  or  to  resort  to  rectal  injections.      In  th, 
-hmild  he  treeh'  iiiveii. 


'   iiiiire  ehi-onie  cases  stiiniilaiits 


1  I  stiotiu.tol  list  patients  with   hiuh  tever  and    much    mental   ex.ate nt 

letiii-  may  l.e  emploved.      I  he   appl^ati ,f  cold  m   the  iiead  and   <|,ine 

which  was  .•ecominende.l  so  stron-lv  hy  the  New  I'li^hind  phvsicians   i,     the 
hrst  epulem.cs  ,u   this  .-ountrv,  is  of  ..reat  >ervicc.     The  ic'e-eap  to  the  hea.I 
and  the  spinal   ice-l.a-  may  l.e  kept   eontinnallv  applied.      With   hi.di  fever 
and  iH^tivc  .leliruim  or  coma  th..  c.dd  hall,  mav  1...  used,  or  cold  HM,n~in..'  or 
It  .UMH^iry  the  cohl  pack.     CounteMrritatio,,   i.  of  doul.tt\.l  hem.lit.  imd  if 

applied  at  all  the  good  eliects  are  prohaldy  ol.tai I  l,v  the  li.ht   applicati.a. 

(it  ilie  I  aipielin  caiiterv.  i  i         "   " 

•H'tl.edrun-  treatment  of  the  disease  we  have  no  s.tisfactorv  knowledge 
imm  has  iHvn  mud.  used  hy  A luencan  physicians.  It  is  panicilarlv  lecm.: 
nu  Hied  h  Siillc.  Ilvpodcrn.i..s  ot  morphine  mav  he  n.ed  in  ivdueiiio.  the 
;."l.'.i-of  the  imisenar  spasms.  It  .hould  he  freelv  used  until  the  sniip- 
toMis  are  controHed.  Mercury  lodid..  of  potassium,  .p.iuiue,  the  s.lh.vlales 
ei-o,  helladon,.a.  au,  calal.ar  Lean  are  a  few  anio.io.  the  I,om  of  dn... ■.'which 
have  heell  .■ccomineniled.  " 


TETANUS    (Trismus— Lockjaw). 

Definition.     \n  a.'ute  ii,f;.etious  .lisease  charac.eri/ed   l.v  tonic  .pa<m.  of 

1h'  voluntary  muscles,  with  marked  exacerhations.    A.  the  di^ea^e  si,  .-J  i  .'  f 

;:r;,;"  "'^'  --'--*•  the  jaw  ,  he  names  trismus  and  lockjaw  haVe  he!';;  aHlhl'I 

Tlie  attivtion  was  well  known  to  the  ancients,  and  the  descriptions  .dven  of 
.t  1'.^  ii.|.pocrates  a.i.l  Arctous  are  partieularlv  .raphi...     The  ,\U,n<'rZ 
";;'..lv  follows  trauma  (traumatic  tetanus,,  hut    mav  occur  spont  ne,,  -        r 
alter  exposmv  tocold  (so-called  i.liopathic  or  rl.eu..u.th.  teta,  u       i.       ■    t 
a:.  n,,,„r,aiit  varietv  develops  in  ..ewhoru  children  (trismus  iu..i;       ,,    '    ' ' 

Etio  ogy.      ihe  .hsease  is  more  fre.pient  ii t   climates   ami  ha<  niv    ,de  I 

exieiiMvely  u.  the  West  Imliesa.nl  1,1  the  Soutl.oru  S  L'of      n     -i  T 

;-|ah,vn.son.e  of  tl.oAV..t   India  Islands  from   ,ri.mu<   nei;,onnn 


iiiiirmous 


Hie  illcid.'nce   of  tl 


riic  colored  nie 


ihn-  11,  the  l'"raiico-rrus 


le  disease  in  militarv  cai 


cs  are   more  prone  than  is   the  Cancan 


tew  , ■;,.,'>  Wei 


an  War  and  ii'i   the  Civil  W 


paiuns  has  varied 


liin. 


V  oiiserve<l 


Tl 


le  disease  may 
14 


1, 


remarkalily ; 
ar  ill   this  count rv  veVv 


cmU'iiiic  III  certain  localit 


le.- 


i 


•210 

Atlcntioi 

of  Loiiji'  Isliiud. 


NERVOUS  DISEASES  AXD  THE  1 1!  TIIEATMEST. 


1  Wiis  ciirlv  ciillc'd  111  tills  cm 


Tl 


IC  (llSl'iiSO    IICCIll'S  illSd 


iiizcd  its  int'cctidiis  iiatiii'i',  as  cases  arc  v 


iiilry  to  its  |)rcvalcncc  at  tiiccast 


in   iiorscs  ill  wiiicli  veterinarians  have  1 


erii 


siiccessivclv  in  tlic  one  . stable.     Catth 


i>rv  a])!  to  (Icve 


op  siiiiiiiianeon>l 


Al'ter  the  first  inontli  of  lite   the   disca^ 


c  and  slieep  arc  also 


alii'ctc 


e   IS   rare   m   ( 


iiihh 


It 


most  f'rc(|ncntly  in  tlie  tliird  and  fourth  ik'cailes.      >rales  arc  somewhat 
f're(|iicntiy  atli'cted  tliaii  females. 


prevail. 


IIHilv 


n  a  vci-v  laiyc 


proportion  of  all  cases  there  i.s  a  trauma. 


nized  spocitic  character  of  the  malady,  manv  now  donht   if  tiie  d 


VIK'C  the  n 


ocelli's  withont  a  h 


the  snrtiice,  tlii'ouuii  wliici 


ISl'ase  i\rr 


1  the  poison  may  lie  iii'r. 


diiccd.     It   may  tldlow  wounds  of  any  kind,  hut   is  more  common  aft 
tnse<l  or  lacerated  wounds,  ])articularly  when  the  nerves  are  involved 


f  the  extremities,  particularly  of  the  hand,  are  ino.st  iiahle  to  I 
focted.     The  di.seaso  ha.s  also  follow(Ml  fro.st-hito  and  burns,  tli(>  rei 


\\' 


"iiiiil^ 


lecoiiii'  ill- 


tooth,  and  even  the  most  tritlinji-  injuries,  as  the  stini;'  of  an  inse 


u>  rcnioNiil 


;i 


ilinter  of  wood.     It   is  rare  after  sui'uical 


opi'ratioiis 


( 'uses  I 


i-'t,  tir  a  Hiiiiij 
lave  orriin'ci 


durini;'  the  proures.-  ol'  vaccination.  A  special  form  of  it  is  met  with  in  .on- 
nection  with  the  open  siirllice  of  the  uterus  after  parturition — the  |inerpir;il 
tetamis — of  which  mention  will  be  made  later. 


It  is  inti-restiiiy  to  luite  that  in  a  larire  ju'oportion  of  all  the  cases  t 


ileiv  i 


i;b 

Nllce    atlcll- 

in  a  considcraliji. 
le  woiind  witli 


been  in  the  injury  a  possibility  of  contamination  bv  the  si 
tion  has  iieen  uiven  to  the  point,  it  has  been  observed  that 
]iro[)ortion  of  the  cases  the  injury  involvt'd  contamination  of  tl 
•il,  as  ill  falls  on   the  aroinnl,  a  puncture  by  a  broken  stick   or  stak(   uImVIi 

I   a  spliiiiiT 

il : 

roiii  a  fall  in 


had  been  in   the  earth,  or  iiy  a  s|ilinter  from  a  dirty  flo(n-.     Sucl 

from  the  floor  of  a  skittle  alley,  penetrating-  beneath"  the  nail,  has  in'oihilrd 


one 


fatal  case  was  due  to  a  compound  fracture  of  both  femora,  t 


which  the  ends  of  the  bones  were  covered  with  earth;  liardeners  liav;  >i., 
fered  from  punctures  by  sticks.  In  most  of  tlie.se  cases  the  telanii>  limilli 
were  fiiiind  in  the  source  of  the  contaminatiiia'  material;  their  prescmi.  r\- 

Uriiv 


dains  the  iiitlueuce  of  tlie.se  injuries.     They  have  been  found  in  spid 


and  tetanus  has  followed  the  api)lication  of  such  webs  a; 


lar  custom  in  some  ])laces),  and  also  the  aijplication  of  earth  t 


1   styptic  I  a 


in|ll|. 


(I  a  wmiiikI 


owcrs. ) 


'n 


le  c.xjicrieii 


)f  the  Civil  Wa 


r  IS  intcrcstinj:-  in  connection  with   iIk'  in- 


stances of  the  (lisea.se  in  militarv  suruH'rv.     Of  ■'»((•")  ca.ses  of  tet; 


iwiuiT  was  the  distribiiti 


on  :  np|)er  linih,  \'.\t  ;  i 


distributed  as  fi 


mil-  ihr  I'lil- 

lows :  dmiil- 
>(  ;  lowiT  liiiili, 


der,  .">1  ;  arm,  .">7  ;  coiide,  7;  forearm,  24;  thumb,  4;  hand 
2!t2  ca.ses  :  hauche,  2  ;  tlii^h,  !l!l ;  knee,  1  7  ;  lea',  !».") ;  coudepied,  22  ;  mihI  . 
57.  It  is  intercstinii'  to  note  that  tlie.s(.  figures  <lo  not  conlirm  the  n-ii,-il  >t,ili- 
nieiit  that  tetanus  more  usually  follows  wounds  of  the  hand  than  of  ijn  t'n"l. 
The  relative  fre(|uency  of  the  disea.se  after  operations  and  wound-  i-  ,i- IM- 
lows:  in  2!),9''S0  amputations  tliore  were  IKi  ca.ses  of  tetanus;  in  jd.ii;  n-d- 


tions  there  wi'i'e  1.") 


CISC; 


and  in  212,07(1  wounds  there  w 


ere  -x  4  ca-i- 


'riir    Trfuiiii.i   lliiri //!(■■<.     The    disca.si'    is    caiisi'd    bv  a   specili( 
discovered   by   N icolaier,  and  siib.se(|Ueiitly  studii'il  elaboratclv  li\    1 
The  oriianisin  may  be  procured  by  iuoculatiui:' an  aj.;ar  till 
wound  of  a  human   beinj;-  sutterinj^-  from  tetanus,  which  in  the  iiuiiliaii.ini 
.'i")"  to  ;{7°  < '.  shows  the  characteristic  drum-stick  bacilli.     "The  hn.illi  i;T"» 
oil 


I'l:;iiii>iii, 

\illl,SII". 


IC  w  itli  |iii-  liMiii  a 


t  into  loiio-  threails  at 


ortlinary  ro(Uii  tcmperalnrc ;   but    form  ili 


fcristic  .spores  at  '■'>'}-  to  ;'.7°  ( '.  in   the  iiiciibalor  in  about    l\\eiil\-rniir  I 
They  then   appear  as  short,  Hue  rods,  with  a   lara-c  round   kiiol 


1  (III  line  ciiil, 


the  knob  coiistilutin^  the  resistant,  friisteuinu-  spore.     The  bacilli   liavc  imli 
pendent,  but  slow  inotioii."     (Holton.) 


MKXT. 


•V  at  tlir  caslcrii  •  n 

lis    liaVC    lolln-    I'lTuM 

i|>  siiiiiiliaiu'ini>l>  ,, 

aHi'ctcd. 
lildri'ii.      It  |)rcv;ii^ 
arc  soiiu'wlial  immi, 


a.     Since  tlic  re  r.,-. 

if  tlic  disease  (Ni-r 
IKtisnii  may  l)c  inii'ij. 

ciiminnii  at'liT  cm. 


\V 


iinii 


ICCdIlli'    III- 


iiividvci 
ai)lc   to  I 

IS,  the  fcinoval  nf  a 
111  insect,  (ir  a  -iiuill 
'ascs  liavc  occiinvd 

is  met  witli  ill  niii- 
tifin — till 


IC  llUcr|i(T;|l 


tl 


10  cases  the! 


ui 


V  iia- 


■"ince   alien. 


It   Ml  a  ('(III- 

I  of  t 


nil  i':il 


ic  woiiml  Willi 
or  staise  w  liicli 


Slid 


UI,  lias 


1   a 
prod  11 


|iliiiii-i 

eed  il  : 


iiora,  from  a  Ihil  in 

■ardcners  liav;>  -iit- 

tlie  telaiiii-  li.iiilli 


leir  |ire<eiM 


tl 

Ild   111  S|)|i|erv    \\rli-, 

'  a    styptic  (a  |iii|iii. 
I'artli  to  a  wniniil." 


ection  u  itli   iIh    in- 
of  let; 


mil-  ihi'  |i 


1  as   foll(l\\>  :    -linlll- 

id,  'Vt  :  jowii-  iiiiili, 
'pied,  '_'•_> :  ami  IImii. 
irni  tile  ii-iial  .-iiUr- 

1(1  lliail   of   llir  tniit. 

il  wound-  i-  a-  t'"l- 
mis;  ill  lii.'ii;  rcxr- 
verc  •"174  ca-e-. 
specilie  iii-uaiiisiii. 
rately  li\  Kiiiisii". 
lie  w  itii  |in-  li'diii  II 
ill  the  iiiiiiliiiinr  Ml 

"Tlie  liurilli  ;;l'ii\v 

It   tiirm  llir  cliiinii'- 

t\veiil\-riMir  ji(iin>. 

knoll  ell  ciiic  ciiil, 

'  liacilli   li;i\('  iiiiii'- 


isriy  -rr  1 1-:  nfsi:.  i  .S7.;,s'. 


211 


ot    u,.„ty-tl,m.  si„.r,nu.ns  „f  s.„l  tak.,,  iV VMrious  parts  of  Cn,,,,!;,,,,,,, 

Hxl.rn  prove.!  vinilnil  when  in.M.i.latr.l  it.i,,  animals.  Th<-  n.<i<taL..  ,  Ml  '. 
,.',an,.aMsv.ryim.at,an.I  the  virus  ha.  provcl  viruh.,!  in  pus  whirh  h  ■ 
lurn  dncM  f.M-  uurnv  mon.lis  Th..  l.arillus  has  Ur.u  ,h.n,„n'stran.,l  in  . 
(hist  truni  the  floor  ot  the  wards  of  a  niilitarv  h..spii.,i 

/Vo./»./.s.  of  ihe(lro.;h  offhr  lianin.     Tin.  tihrat,.  of  ,h,.  ,.uit,nv  thr.v  or 

om.  w(rks  oh  ,  nmrHv  tr,r  troM,  .,vrn.s,  Hnnain>  the  sp.,.iH.  poison  of  ,.,uu, 
from  uinrh  I?n.-vr  has  separatcl  two  hasi,.  ho,li,.s.  whi,.!,  aro  raih.,l  t.'  '      „' 
ami  t,.tano-toxuu.        Hru......  and  Kra,.nk,.|  havo  also  separated       1  e  "! 

MlhuM.en.  hut  tlu.  true  eiu.inu.al  nature  of  the  poison  hai  not  lurn  acrur,  .-Iv 
(Iciei'innieii.  man  i\ 

With  the  pro,lnets  of  the  orowth  .,f  th..  tetanus  l,a..illus  the  disease  is  very 
ivad, Iv  produced  ;;^'T<;''"n-uta  Iv  and  eoniparativly  small  .h.ses  are  ronuired 
„.  kdl  a  n.ouse-(..()(.l  eem.  ot  the  filtrate.  Oou-s,  whieh  are  in.mune  ,  at  ' 
al iv,  re,|U,re  a  proportionately  lar-er  dose.  The  poi.son  is  not  ef!;.etiv..  w  u 
a,hnnnst..red  thron_.-h  the  .sfon.aeh.  Th..  .li.sease  prodneed  ..xmh  r  men  '  I  - 
present,  a  pieturestnular  to  that  seen  in  tuan.      It   is  interestin. ',,!    .,  ,  ,'    .;; 

•  ;■  '•'■=' ^  '''7''"i;  '^''^f  '"  ''":  "...sel,..  near,.,st  ,|,..  .seat  of  inoenlation.     The 

etleets  a.e  produeed  l.y  the  poison,  not  l.y  the  ha.alli  at  the  site  of  the  inoeu- 

atiou.  I  Ins  ,.s  shown  l.y  the  aet  that  the  id.M.tieal  sv.npton.s  are  pro,  n e  1 
hy  the  .enn- ree  hltrate  ot  the  pure  ....Iture,  and  al.so'hv  the  in'tere' „!■ 
.xpernnents  ot  kttasato,  who  u.jeeted  the  tetanus  baeilli  i„to  a  .uouse,  at    he 

oo,  of  the  ta.l,  and  oxc.sod  and  burnt  the  seat  of  inoenlation  at     a  i  ,< 

iM,es  atterwani,  a.s  halt  an  hour,  an  hour,  an  hour  and  a  half  d,.str.,vin '■  n 
lias  way  all  the  haeill,  at  the  seat  of  in.,eulation.     Onlv  those  anima  s 

"'";•''  ""Vr""^  •!♦  '''"*'"1'" «as  treated  loeally  l.y  ineision  and  hurniu.^  ha  f 

^"!   ':'nr  after  u.jeefon  reo.vere.l ;  the  othe.s  die.l  of  the  .lisease,  showin-': 
witnn  an   hour  enough  ot  the  pot.on  is  absorbed   to  produ.v  the  svn.pto 
and  eause  h,  al  results.     There  arc  .several  very  inter.Uiu,-  points  A\SuZ 
worked  out  about  the  production  of  the  poison  ;  th.is  it  has  be,.,,  shown  tint 
-lu.M  the  eiiltures  aiv  orowii  at  20°  to  22°  C.  thev  do  not  tbr  s..vo  a   .■  n 
I'l'-diuv  any  p,.is..n.  and  are  m.  longer  virulent.     Jt  is  interostin.r  to,,  to  n.  e 
that  tlu.se  n,ai-p,,,som,us  baeilli  may  bec.ine  toxi,.  when   J'^wl        1  "X 

'nns  not  ..apable  ot  pro. hieing  the  .lia.a.s,..  In  a..ei.leutal  infe,.t  ,n  h e 
l.-al  suppuration  pr<..luc...  by  ..th..r  .u-anisn.s  iuo,.ulat..,l  at  the  same  ti  e 
navfurinsh  the  very  e._.u,liti,.n  fava'abl..  f.,r  the  l.ro,lu,.tiou  of  ,h  t  t  i  is 
I"-']!.,  llH'r.Ms..xp..r.mental  evi.l..u,.e  to  sh..w  that  th..  poison  w,.,  !  ko 
strvi'hiim,..  an,    has  its  M,.tt,,M  ,..w.„  fi, ,,,..:.. ..1  i  '  '^    '"^"^ 


lis  its  aetiou  up,.n  tlie  srinal  eonl. 


tl] 


Morbid  Anatomy.     Tlie  eon.lition  ..f  tl 


nerv.'s  in  the  loealitv  I 


liave  l.ei.u  ti.un.l  re.l.l(.n<.d 


K'  W(.un.l   is  variable.     \' 


laajority  of  the  ea.se.s  they  have  be<.n  norma 
HI  till,  brain  ..r  e.)rd.     (_' 
porivas,.|ilar  exudation,  ii 
I'i'i'a  d,'s,. ril...,l,  but  these  .•! 
.'rcliyiiiii-es  are  eoininor  on  thesei 

LTSti 


I.     >■ 


ami  swiilK'n,  but  ii. 


ift(.ii 


o  charaeteristi..  l..si..us. 
cs.-:('ls,  small  h 


i>nge.sti.iii   of  th..   blo,),lv 

i..rease,l  pi.oinentati,.n   in  the    (.annlion   cells  I 


a 


is,.ecur 


cm.)rrliai;e( 


liangesare  neither  iinifbrni  nor.li.stii 


111  i.f  the  lungs  are  tVe.piently  j.re.sent.     1 


I'csiilt  fn ini  tl 


Sympcoms.     Foil 


ic  int(.nsitv  ..f  the  spas 


'..us  surfaces.     (Kilenia  and  h\ 
tii].tur..  ..f  mus.'l 


lavc 

ictiv...     Minute 

postati..  .',.11- 

i*.  fil.r(.s  niav 


iisualb 


flLsi'S,  Mliil  lu 


owing  an  injurv  th..  first 
laaiiifest  within  ti'ii  davs.    "in  Vaudel 


.h.b 


s  stati.sties  in  ibiir-fiftiis  of  ti 


indicati.dis  of  ih(.  disea.se  are 
tatistics  in  tw<.-tift]is  of  the 


legan  l.,.f,.re  the  fifteenth  .lay.     Slight  stifiiiess  of  tl 


le  cas..; 


tlie  symptoms 


clcsef  il 


iaw  is  the  earliest  featii 


iicek  and  of  th."  ji 


111,- 


'II  iiiastH'atioii,  or  that   tl 
laikiii"-. 


r...  or  th,.  pati..nt  complains  ,.f  ,liHicultv 


10  m,.veinents  of  tl 


tongue  are  not  .so  t 


ree  in 


I 


21-2 


xfuvoi'.^  diseases  axd  their  ritEATMEsr. 


Ill  a  few  cases  cliilly  i'coliiigs  or  cvfii  rijidrs  may  iircccdo  tlii'sc  syiiiiilm  ;-. 
ami   till'  a  day  or  so  there  may  lie  sensitiveness  or  even   pain  in   tlie  Wdiin,! 
(iradiiailv  tlie   tonic  sjiasni  of  the   muscles  increases  until   the  condition  ,,| 
trismus  or  lockjaw  liecomes  so  marked  that   the  jaws  are  separated  willi  ih, 
ureatest   ditticiiltv.      With  the  muscles  of  mastication  those  of  'he  face  mi, 
also  involved,  so' that  the  aiiiiles  of  the  mouth  arc  drawn  outward  ami   uj 
ward,   prodiicini:'  the  sardonic  ,i;riii,  »•/.<((■•<  surdiiiilcii.-'.     With   increasing:    in 
volvemeiit  of  the  muscles  of  the  neck  the  head  is  drawn   backward  and   ih, 
ninscles   of  the   back    heconie   ri,i:id,   and    the  contraction   may    lie  vWhi,, 
cnonu'll  to  cause  marked  archiiiu'of  the  verteliral  column.    The  liody  may  iji  ( , 
remain   |ii'rfei>tlv  straiiiht.  the  comlilioii  known  as  orlhotonos  ;  or  de|ieihliii_ 
upon  tlicstrcii,i;'tliof  llii'  spasm  of  the  dilltTcnt  ,i;i'on|)s,  opisthotonos,  in  wIilI, 
the  back  is  arched   like  a   bow  ;  emprosthotonos,  in  which   the  body  i>   In m 
forward;  or  plenrosthotonos,  in  which   it  is  turned   to  one  side,     'i'hc  hh'- 
spasm  iiiav  involve  the  mnsclcs  of  the  Iciis  and  arms,  but  as  a   rule  the  ;i!!;,- 
aml  hands  are  not  much  affected.      While  the  riiiidity  is  tonic  in   cliai.h  i,  r 
there  are   fi*e(|Uent    clonic   exacerbations,   which  arc   a|)t    to   be   excind   li\ 
peripheral  irritation,  such  as  a  dranuht  of  air,  or  a  touch,  nv  a  noise.     Tli,-, 
exacerbations  vary  very  much  in  fre(|ueiicy  and  severity,  and  they  beai-  -iik 
proportion  to  the  intensity  of  the  disea.se.     At   tirst   the  riu'iiiily  is  ikiI  \(|\ 
painful,  but  subsei|Uently  the  suHerin.i;-  is  extreme  I'rom  the  violent   cniiii;i,. 
ti<ai.     In  verv  severe  attacks  the  thorax    may  be  rigidly  compressed   li\  iIh 
muscles.     The  respirations  are  rajiid,  and  sjiasm  of  the  lilottis   ma\  i.,,iii 
causini;'  asjihyxia.     in  the  severe  paroxysms  sweatiu.u-  may  be  piofuse.     ili, 
heart'saction  is  increa.sod  diirinji'  the  par^  \ysiii ;  the  pulse  may  lu'  finm  im 
to  Klb^.     The  temperature  is  very  vari.dile.      I*  may  bo  normal  thinni^lh.ui 
or  ])resent  onlv  a  vt'ry  sliulit  increase.     In  a  few  cases  the  disease  is  asHni.ii.d 
with  hvjierpvrexia,  particularly  as   an  ante-mortem   plieiiomcnon,  and   ilim 
are  instance.s  in  which   the  body  heat    ha.s  reached   from    IIH'  to  111  .     Th, 
urine  is  scantv,  and  accordin.si'  to  Senat(U'  the  amount  of  nilroii-eii(in>  iniuhr 


,!1 


is  not  increased.     There  may  be  retention  from   spa.siii.     1'Ik'   mind   ii-n;iin 
remains  clear,  except  toward  the  close  in  protracted  ca.ses.     Death  may  nrcm 


dnrini:'  a  paroxvsm  either  from  asphyxia  or  cardiac  dilatation.     Tin  it  i- ; 
instance  on  reeiM'd  ir.  which   rupture  of  the  walls  of  the  heart  occunvd 


III 
iir- 


iiiii'  the  violence  of  the  sjiasm.  In  other  cases  the  fatal  result  is  brdiiulii  .m 
by  exhaustion. 
There  arc  certain  varieties  which  are  of  interest.  In  the  //--(r/-/, /.»,/"- ni 
Hose,  which  has  followed  in  a  majority  of  instances  wounds  of  (he  I'act ,  iii- 
mus,  (Ivsphauia,  respiratory  distress,  and  facial  paralysis  are  tln'  iinniiiiinii 
features.  Oil  account,  too,  of  the  spasm  in  the  dei;iutition  niu-cl.-,  iiii'l 
conseipiciit  dilKenlty  in  deji-lutitioi',  this  form  has  been  called  alsu  iriaiii- 
hvdrophobieiis.  Tlie  caur^e of  the  facial  paralysis  is  not  kiiown.  Th.  iv  niav 
be  al.so  paralvsis  of  the  eye  innseles  on  the  same  side.  This  iiiodiricaiion  i- 
uot  verv  common.  .laiiin'  has  collected  all  the  cases,  thirty-one  in  niiiiiln  r. 
11))  to  i.S!l2,  and  he  regards  it  as  a  form  in  which  the  toxic  niatnial- ;ui 
chiefly  in  the  medulla.  The  attacks  recur  at  varyinu;-  intervals.  Imi  iin  v 
may  lie  id'iiost  continuous.  In  other  cases  they  are  extremely  sli'.:lit ;  iIh 
most  serious  attacks  are  those  caused  by  atteinpliiiL'  to  take  food,  wlnii  llun 
may  Iks  si)ii.sin  of  the  museles  of  deirlutition  and  j;reat  interfcreiicr  wiili  ili' 
res]  I i  rat  ion. 

7V/,f//(),w  ii'-Dii'il'iriiiii,  a  rare  form  in  temjieratnre  reii-ioiis,  ami  I'diiiiiiMlrlv 
now  rare  in  the  trojihie.s,  was  formerly  very  common  in  certain  inuiinn-, 
jiarticularly  in  the  West  Indies,  where  in  some  islands  one-half  ol   iliciiiri" 

I  I'nris  Tlic'sis.    I)n  Totiuios  lUilbiiire,  1892. 


[i:sT. 

.■  ilu'sc  syinptiiiii". 
);iiii  ill   tlu'  wciiiinl. 

I      lIlC     ('lllldilioll    n| 

s('|iiiral('<l  with  ilir 
sc  of  tlic  tiler  ;iiv 
I  (Mllwai'il    illld    ii; 

illi  iiicrcasiii::  ii, 
hacUwiird  ami  ;  i . 
may  he  cMirn,, 
lie  IkmIv  iiKiy  I'll  III : 
nils  ;  or  (Icin'iiilin- 
ihoIdiKis,  ill  u  liii'li 
I   till'   liddy  i.-  lull! 

I'    side.        'I'ilr    Inliir 

as  a  rule  I  iir  :iiiii» 
tonic  ill   cliaiariir 

to     1)C     CNcilril    li\ 

or  a  noise.     Th, ., 

ind  tliey  Ileal'  - 

•iii'iiiity  is   ih'I  \iia 

llO  violent     enllllllr- 

(•( )in|)l'( 'ssed  li\  ill, 
li'lottis  may  nrrwr, 
:  he  profuse.  Tin- 
may  he  t'rom  |:;ii 
lormal  tliriiii-li"ni 
list'ase  is  asMirimnl 
[imeiion,  and  iliciv 

l(tMoll4^      Tllr 

iiilrou'eiioii-   iiKillM' 

'I'lie   mind   ii~ii;i!K 

Dealii  liia\  nrnii 

llioll.       TluTe  i-  Mil 

leart  oceurrnl  iliir- 
I'.^iill  is  liroiiLilii  "11 

tile  III  ii(l-tiliiiiii'  "( 
Is  (if  I  lie  lace,  hi- 
are  tlie  prniiiiiieiil 
ilioii  imi^elc-,  mill 
called  al>o  lel;iiri> 
now  11.  Tli.'i'r  nun 
riiis  modilicjii'iii  i- 
irty-oiie  ill  iiiiiiiliiT. 
toNic  mali'i'iiiU  ;iii 
illtel•val^,  liiit  dirv 
livniely  >li'jlil :  iln' 

<C'  fiiod,   wlirll  lllilV 

U'rt'orcncc  uiili  I  In 


lis.  and  fiii-|iiiialiiv 
1  certain  cniiiitni'. 
e-half  of  ilifiir-M 


I* 


5 


: 


lik 
liii' 


ml 

in] 


Mi'e 


Ult 


llu' 


OIK 
(111.- 


.'Ill 


IIIU 

III! 


irii 


nil 
lidi 


tiiti 
thr 


It  I 
the 


ma 


iSFHcrivi:  iiisi:.\si:s. 


21:] 


(lilMr'clMlicil  (if  lllc    ili>cil,-f.       Ililliliy,  ill    lii-    Dis,, ,..,..    I>,r„/;,ir   h,    III,     ll'oV 

liulilt    hlilllils,    uivcS   the    tilllowilln'     nn,|,|,i,.    ,„.,,, ,    ,,|'    III,,    ,li„,|.,|,.|..         ■•    |.',,|. 

wliiii  till'  child  isns  i|i  tliis  iniscnililc,  riiii.!,  iiiiiiK.viiliir  cnnditioii,  ii|m,ii  mov- 
;ir.  its  Imiiils  or  fi'ct  in  the  must    identic  iiiiiniicr,  or  xifilv  Iniichinu  jiiiy  j>;itl 

nt   il^  IkhIv,  oi'  ,-iviii.i;'  it  the  Icnst    tioii,  even  fcciiii-    its   |.iilsc  iii  lii.''  iiin.-t 

-clltlc,  tender   niiUlller,  or  liie    least  IK.ise.  ur    even    Inwellini:    its   eldtlies,  will 

'ii'i'M^  "I'  'Ik'  ' vnisive  s|iiisiiis,  and  eiinse  it  to  lie  -truii-iv  eonvnised  hack- 

•Aiinl,  nr  drawn  intoa  ri;;id  sirai-lit  line,  slnainlv  extended  iiml  iimiinvahle 
like  a  statue,  and  will  so  remain    iiiiniovahle  out  of  either  of  iho-e  |iostures, 

i''i'  i'  I sideralile  time,  a   minute  or  two."     (Kditioii    l.v  I'.eniamiii    \{\\Ai 

l.slh. 

Ill  the  Southern  States  .il'  Aineriea  the  disease  was  tormerly  Very  eomnioii. 

I'lierperal  tetanus  is  now  fortunately  rare,  hut  i'ornierlv  in"  some  countries 
ii  |, roved  the  inost  fatal  of  all  tornis  oi'  the  disease.  The'disease  he^ins,  a-^  a 
rule,  within  live  or  ten  days  after  parturition.  In  a  immlier  of  cum's  it  has 
fiijliiwed  ahortion. 

Whetiier  tetanus  ever  occurs  idio|.alhically  has  iieen  dnnl.i,.d,  Imt  liiere 
niv  cases  on  rei'ord.  particiihirly  in  army  jiractice,  in  which,  without  anv 
:i|i|iMrciit  externa!  injni'y,  the  disease  has  developed  after  expo>ure  to  cold. 

Mirhilihj.  ^  'fhe  prognosis  is  always  extreinelv  urave.  and  two  of  the 
aplinrisiiis  of  Hippocrates  may  he  ipioted  at  the  present  dav.  namely,  "the 
spasm  siiperveninu'  <>n  a  wound  is  fatal,"  and  "such  peisoli.-  as  aiv'sei/ed 
with  tetanus  die  within  four  days,  or  if  they  pass  these  they  recover."  In 
llic  iraiimatie  eases  the  dcalh-rat<'  is  not  less'than  -SI)  per  cent.  In  the  eases 
which  develop  without  any  wound  the  moi'talitv  is  not  nearly  so  hi-h.  From 
tile  puerperal  form  recovery  is  .■xces-ively  rare,  and  the  lorni  iiT  infants  i> 
also  very  fiital.  J)eatli  occurs  from  asjihyxia.  or  from  heart  strain,  which  in 
one  rA<v  ha.s  resulted  in  rupture  of  the  wall.  Kavoraldc  indications  are  late 
ousel,  ahseiice  of  fevei',  and  localization  of  the  spasms  to  the  muscles  of  the 
neck  mid  jaw. 

DiagnosLs.  In  well-developed  cases  tldlowiiio-  inj\iry  no  [lossihle  ditticulty 
could  ari~c.  h'rom  strychnine  poison in,i:-,  which  presents  verv  similar  mus- 
cular spasms,  it  is  dilll'i-entiated  hy  the' followini.;'  jxiints:  The  anamnesi-, 
the  rapid  development  of  the  symptoms,  and  the'  n-reater  extension  and  the 
ivliex  spasms,  as  well  as  the  fact  that  the  Jaw  muscles  in  strvchnine  poisoii- 
iiii;-  are  not  involved  early  if  at  all,  and  lu'tween  the  paroxvsiiis  there  mav  he 
Ml.  iiHiscular  riu'idity.  These  points  should  sutlice  to  (Hstiimuish  it  Inun 
strychnine  poisoning-.  TluMpiestion  has  lieen  raised  l.v  t  he  defence  in  murder 
trials,  as  in  the  celehrated  Palmer  case. 

In  hy(lroi)li()hia,  for  which  the  head  tetanus  mav  l.e  mistaken,  there  is  no 
special  spasm  of  the  Jaw,  or  any  ri,L;-iditv  of  the' muscles,  or  ].ar.ixvsms  in 
wliich  the  cervical  and  dorsal  nniscles  an'  involved.  In  tetanv  the  ('listrihu- 
tiniinl  the  spasm,  chicHy  in  the  hands  and  feet,  the  special  involvement  of 
I  :c  hands,  their  peculiar  positiim,  ami  the  conditions  under  which  it  develops 
should  suffice  usually  to  separate  the  afiections.  Ilvsteria,  which  mav  imi- 
tate almost  any  one  of  the  diseases  with  motor  i.he'noineiia.  rarelv  [.resents 
the  picture  of  tetanus.  "  IJut  trismus,  causiiiii-  persistent  closure  of  the  jaw. 
occurs  111  hysteria.  It  may  succeed  a  c(mvnlsion,  ami  last  until  another,  or 
it  iiiiiy  (•oine  (.11  without  obvit.us  cause,  continue  for  a  few  hours  or  davs,  and 
then  sud(l,.nly_vanish.  It  is  prone  to  recur,  and  this  character,  the  su.lden- 
iK's-^ot  onset,  Its  complete  decree,  and  the  ahscnce  of  riiziditv  in  the  neck, 
iiiid  the  presence  of  other  symptoms  of  hvsteria  will  rarelv  leave  anv 


lis  to  lis  iiaturt 


(( 


doulit 


lower.- 


riic  l.acteriolooical  diau'iiosis  is  of 


I'l'i'l'' hon,  th,.  pus  of  the  wound,   from  the  «• 


onie  importance.     Cultures  should  Ir 


ranulatioii  tissues,   from  tiie 


1 


214 


ynnvoi's  i)isK.is:-:s  ami  riir.in  ti:i:atmi:nt. 


'{ 


. 


i 


splinliT  (if  wood,  or  tVoia  the  ciirlli  in  llif  pai't  wlicic  tlic  wound  \\ii~  - 
ceivi'd,  or  iiortioiin  may  lu'  iiioci.lati'd  into  ii  mouse,  wliicli  is  the  animal  ini-i 
siiscci)tii)l(',  and  wliuii  usually  dies  within  a  few  daye  of  the  inoruiatiiMi. 

Treatment.  /////)/((-  ■.'///('//.  Tin.  lu-.'ScMt  status  of  this  (jufstion  with  1,1 
crcncc  to  ti'tanus  nuiy  lie  thus  stated:  Animals  which  are  very  sliu-htly  i- 
eeptihle,  such  as  the  doir  and  hen,  can  lie  rendered  immune  hy  the  injeeii  i„ 
of  ji-railuallv  iueri'asinj:  iloses  of  the  tetanus  viru>.  The  serum  of  animal  -n 
treated   has  the   power  of  eonferrin;.'  immunity.      For  more  suseeptilile  .1111 

nials  Hehrinj;'   employe(l  the  houillon   cultures,  diluteil  with   the  aihliti f 

iodine  trichloride,  lie'i^inninL'  with  a  culture  eonlainin;.'  d.".'.')  per  cent.,  tlicn  :i 
|iercentat;c  of  lt.2,  tlie  1  a  pereentaue  of  0. l.'s,  and  ultimately  the  undiluiid 
culture.  The  serum  of  aninuds  imnuiui/.ed  in  this  way  may  he  prcMivnl 
with  (•.()  per  cent,  of  carliolie  acid,  and  may  he  used  for  imnuini/iuL;'  oilm 
animals  not  previously  treated.  The  material  used  hy  'I'i/zoni  ami  Catani  in 
their  observations  upon  nam  is  t!ie  serum  of  the  imnmni/.ed  dojr  treate(l  wiili 
alc(diol,  hy  which  they  ohlained  -i  naiterial  known  as  the  tetanus  antitoxin. 

Animals  inoculatei'l  with  I'alal  doses  of  tetanus  poison  treated  with  iIk 
serum  of  imnmidzci!  animals  have  recovered.  I'p  to  the  early  pari  iif  l-<!i| 
about  a  dozen  ea.ses  of  tetanus  in  man  hail  heen  treated  hy  the  Tiz/oni- 
Catani  antitoxin.  The  jicneral  expression  of  opinion  hy  experts  in  iln' 
(piestion  of  serum-therapy  in  tetanus  is  not  althoucther  favorahlc ;  ilni- 
Klempererand  Levy  in  their  recent  v.orks  on  clinical  hacterioloizy,  IMM, 
(pU'stioii  whether  a  siire  ami  undoid)le,  re>ult  has  been  obtained  in  any  on. 
of  the  cases,  as  the  healed  cast's  wer.  not  so  acute  that  the  projiuiis's  w;i-  1  n- 
tirelv  thaibtful.  On  the  other  hand,  Ivemesotf  and  i'"edorolf,'  in  a  r( n  ni 
report  of  a  ea.sc  supposed  to  bo  cured  by  the  serum  of  an  immuni/eij  aiiimiil, 
claim  in  a  review  of  tlie  rec(a'ded  cases  that  the  duration  of  the  di:-oii|ri' i- 
decidedly  diminished  by  the  treatment,  that  the  temperature  is  reduced.  ,lic 
attack.  ,.f  spasms  are  le.ss  severe,  sleep  is  promote<l,  and  a  very  L;rc;ii  im- 
])rovement  in  the  Lieneral  condition.  Hecenl  reports  by  ( iilman  Thuiiiii-Mii 
and  others  are  altoi^cther  more  favorable,  and  the  antitoxin  should  In-  u-nl 
at  the  earliest  ajipearance  of  the  symptoms. 

8ur;iical  mea>ures  are  usually  employed  at  the  site  of  the  lesi(jn,  ^urji  ;is 
burning;  or  excision  of  the  sear.  I'nless  done  very  promjitly  experiiiic  iii;ii 
evidence,  as  mentioned  above,  would  indicate  that  they  are  not  of  inucli  iiii- 
portaiiee,  and  this  is  borne  out  by  experience.  Kxeision  of  the  nerve-  :ii  \\\v 
part  and  stretchin;,'  have  also  beea  employeil.  Thoroujrij  cleansing;-  ami  di- 
infectin.iz' of  tlie  wound,  po.ssibly  excision,  arc  the  nio.st  ju.stifiable  reiiuilic 
The  ^■eiieral  management  of  the  ca.se  is  most  imjiortant.     The  patieni  -ImiiM 

be  in  a  darkened   ro attended    by   only  one  person  at  a  time,  and  nil  inii- 

side  ( ununieation  should  be  forbi(lden.      \'eteriiiarians_  haVe   Ion.-'  apjinri- 

ated  the  importance  of  complete  seculsion,  and  in  many  of  their  well-ei|iii|)|itil 
intirniaries  there  is  .seen  a  brick,  padileil  chamber,  in  which  the.se  ca-i- ;nv 
treated.  Tlie  <pK'stion  of  feedinji-  usually  becomes  very  in  portant,  ov\iin:iii 
the  presence  .if  lockjaw.  The  (bet  should  be  restricted  to  nourishin-  Instil- 
and  milk,  which  usually  can  be  taken  throuizh  the  teeth  even  when  ili.n  ^ 
S[)asm  of  the  jaws.  If  necessary  food  can  be  introduced  into  the  sIoiikk  h  liy 
a  catheter  p'a.ssed  thronuh  the  nose.  The  teeth  li.ive  sonu'tinu'- Ii'Hi  ex- 
tracted In  such  cases' we  should  trust  for  a  time  at  least  to  the  imtriiive  in- 
jections. 

The  dm--  Ircatmeui  eoii.-ists  of  the  administration,  in  first  place,  ■■!  ivnu'- 
dies  which  relieve  the  spasm.  For  this  purpose  chloroform  is  the  ni"-i  s;iii- 
factorv,    thoULdi   unfortunatelv    the  attacks  recur  as  the  eHects  p;i--  awiiy. 


I  CeianiUjl.  1'.  Hiikt.,  isill. 


V... . 


'^ 


ENT. 

IC     Wdllllll    Wil-      ' 

s  tlic  iiiiiiiiiil  III  >M 
I'  iiiiH'uliitiiiii. 
(|iu'sti(iii  willi  I.  I 
vcr\  sliiilitlv  I- 
(■  liy  tlic  iiijcri  i  ... 
iMiiii  lit'  iiniiiial  -I. 
re  ■'iisci'|)tilili'   Mil 

h   tlic  ii<l(!iii I 

)  per  cent.,  iIk  n  ;i 

tcly   tlic   Ullllillliril 

iiiiy  lie  |ircMi\ .  ,i 
ililllllllli/illL;  Hi  III  I 
loni  iiiid  ( 'iiliihi  ill 
1  iU)'^  trciilcil  Willi 
L'taiiiis  antili.xiii. 

treated  with  tlic 
[•arl.v  |iarl  nf  I  >1I4 
(I  by  the  'ri//nni- 
ly   cx]ierls  in  \hv 

t'avoralih'  ;  thus 
lacteriohiLiy,  I'^'.M, 
itaiiie(l  in  any  mn' 
iu'duiios's  wa-  111- 
di'dtr,'  ill  a  i(  iiiit 
iiiiiiiini/.cd  aniiii;!!. 
(if  the  disiijihi'  i- 
lire  is  reditciil,  ,iir 

a  very  lircnt  im- 
i  iilniaii  'rhiiiii|i-i.ii 
in  slionhl   ln'  ii-nl 

tlie  lesidll,  -llrli  ;is 
|itiy  cxiicriiiKiitiii 
e  not  of  iiinrii  itii- 
f  the  nerve-  at  llic 
(■lean.--iiiLr  ami  ili- 
isiitiahle  riiiinhi-. 
riie  patieiu  -liniiM 
,  time,  and  all  mil- 
iaV(^  lonu'  aiiprici- 
licir  \vell-ei|iii|i|"il 
icll  these  en-c-  ;iiv 

I  |)ortant,  nwlu-j;  tn 
noni'isiiiiiLi  lii'ntli" 

I'veii  when  llu'i'c  i> 
ito  the  stoiiiaeli  liy 
onietinio  hii'ii  I'X- 
to  the  nutritive  in- 

rst  jilaee.  !'!'  remo- 

II  is  the  nil  1-1  satis- 
etlcets  pa-  away. 


ll 


f. 


\ 


isii.rrivi:  hisi:.\si:s. 


2  IT) 


Nilrili'  lit'  aiii\  I  iiiiiy  lir  irinl  lin'  tlir  sun.'  |iiirj.H.r  in  liU'L'f  ilci-r-,  uimI  in  llin 
-iM  II'  |>iinix\>in-.  the  ^mlilm  iiiliiiliitinn  -onicinni'-  cini.-cs  rcluxiitinh.  .Mm- 
|,|iiiir  niMV  Immim'iI  I'di-  the  siiinc  |inr|iusc,  nrnl  in  xirnc  iustaiiccs  has  scfnuMl  to 
li,  iiciiially  cniativc.  ('Iilural  liyilratc  lia-  liicn  lai'L^flv  iiscil,  Tu  lie  cUt'c- 
li\,  il  must  lie  iiivcn  in  cluscs  nl'  tVnm  a  ili'arlnn  in  Iwn'ilraclnn^  in  the  ilav, 
aihl  iiici'iusinj:.  In  llic  tetanus  ni'iinalunun  it  ^Imiilil  lie  mxmI  in  |)in)H,rliuii- 
Mhlv  snialli'r(lnscs.  It  may  lie  «nniflimc>  •umiminl  with  tlir  iin.miilc  nf 
|ioiassinm.     Thf  ( 'alaliar  lican  has  liccn  nscil  .-nccc-liillv  in  >cimc  ca-cs ;  also 

I  lUMiy,  which  nui.^l  Ih  miiihiynl  in  laruc  (hiscs,  a-  di  as  a  i|narlir  nr  half 

!i  iiniiii  I'Vi'iT  hiair  or  twn.  It  i-  nut.  Iiowcvir,  uilln.nl  ilam:iT.  AnKini; 
iilliir  iiu-ans  which  have  iiifn  iccdninaiiiliii  ni'c  llic  cnntinniMis  warm  liatlis] 
iniii  the  a|)|)licatiiin  u['  ice  tn  the  >|iine,  ami  electiieity  tnid  lijiedin--.  In  the 
vvcivr  >|ia>Mis,  leaiJiiiL:'  to  -to|i|,ii,i;e  of  re-ja ration  ami  eyano-is,  ai'iilicial  res- 

hiiation  -iioulil   he  ac|ivel\    empinxed. 


HYDROPHOBIA     (Lyssa— Rabies). 

Definition.  An  acute  infectiou-  di-ease  of  unimals,  dependent  n|i<Mi  an 
iiidsiiiivvn  -[iccilie  iioisiai  cunniiunii-aled  to  nam  lp\-  iiioenlation. 

Ill   animiils  the  disease,  kw<y  ial>ies.  is   niel  with   chietiv  in    iIk        r- 

iiivdia,  |iarticularl\- d(i-<  ■■  '  w.,,  ^.  Jt  is  c(anmuiiicated  from  animal  to 
iiiiiiiial  hy  inoculation  :  ,.,  the  exti'eiiie  rarity  of  the  diM'a.-e  iu  countries 

Mich  as  N(a'tli  (ierm;in\,  wliere  the  inu//iiim  of  do;rs  i>  rii;i(llv  enfcu'ced.  It 
i«  net  infrei|iieiitly  ■onimiiiiieated  hy  iiiocnlatiiai  to  cattle,  and  oceasionallv 
In  horses  and  pi--  It  1>  said  tiiat  iu  the  Western  States  the  skunk  is  par- 
liiiiiarly  liahle,  ai,d  anunilier  of  instances  have  heeti  reported  ot'  the  disease 
fniliiwiiiL;-  tile  l>ite  of  this  aiiiiiail.     In    ihe  doir  the  earlv  sym])l(uii-  area 

cimiiire  in  the  dispo.sitioii  :   it  Ik mes  ipiiet,  dulj  and  heavv,  and  vei\   irritii- 

hic  toward  -trauuers.  The  hark  may  have  a  jiecuiiar  riu;.dnu  (duiracter. 
'lie  nil'  >  iu)t  take  its  (U'dinary  food,  hut  eats  all  -orts  of  ;irticles,  such 

:i- -"■•;         '••  ^^ 1.  I'lul  clirt.      In  soini'  instances,  the  Mi-called  furious  rabies, 

llicni-  \eiy  much  excitement,  hut  in  a  majority  of  ea,ses  the  symptoms  are 
lailnr  iImm^  of  the  duud),  or  so-ealle<l  paralytic,  rahie-,  in  w'hiidi,  after  a 
ti;iii-iriit  -lanv  of  excitement,  there  is  imsteailiiiess  iu  the  leu-s,  with  iucreas- 
iiiL;  wciikiiess  anil  ultimately  paralysis  and  coma.  Tlic  puiMm  i<  present  in 
llii-alivai-y  i^iands,  in  the  nervous  system,  central  and  p.  ripheral,  and  in  the 
piiiiiieas,  adrenals,  and  mauimie.  'I'he  disease  mav  he  produced  in  animals 
liy  the  inoculation  of  portions  of  these  -trnctiires. '  In  raiih'.cs,  the  animals 
iMially  employed,  inoculation  is  made  heiieath  the  dura,  and  death  follows 
III  fioiii  seventeen  to  nineteen  days.  The  virus  prepared  for  the  protective 
iiK'i'iilation  is  olitaiued  hy  passiu--  through  a  series  of  rahhits,  when  it  is 
tniiiiil  ;itter  successive  inoculations  that  the  incnhatioii  period  is  reduced  to 
-I'Viii  days  and  hecomes  remarkahly  uniform. 

Hyilropiiohiii  is  il  rare  disease  in'iuan  in  the  Tnited  States.  I)ulle>,  from 
•hiiic  I,  l.sx.s,  to  .January  1,  1S!)4,  collected  seveiitv-eiirhl  cases,  an  aveiai:e 
-t  t.Miiiirii  prr  iinnnui.  Sixty-two  per  cent,  of  the'cases  were  in  the  Atlantic 
^iMli's.  Ihe  disease  Ts  nuieli  more  eoinnion  in  Kurojie,  p.irlienlarlv  in  Itussia 
and  ill  l"i-;nic('. 

Incubation.  There  is  an  extraordinary  variahility  in  the  time  which 
i'hi|i-.|..  !-.etwe«i  tlie  iutniiluciion  of  the  vini.-  ami   ll'ie  appearance  oi'   the 


iia|iloias.     Horslev  .states  that   tl 


tiwtiirs:     "if.  Ai 
Fur  111 


Th 


le  variation  depends  u|)on  the  following 


!■  nliviims  reasons  the  f 


e  nil  nhataai  is  shorter   in   children   than    in   adults. 


r.rlrd.       Th,, 


or 


ner  are  more  fre.(uently  attaidvcd.      h.    Part   iu- 


•apidity  of  onset  of  tiie  svmptoms  is  i;reatlv  determii 


led  l)v  the 


216 


Xh'nVOUS  DISEASES  AM>  TJll, 


in  'mEATMEXT. 


i  7\ 


part  of  tlic   l)(»|y  wli 
tlic  fiicc  iiiiil  head  ill 


i<''i   may  liappcii  i,,  liavc  U-vn   hittvi 


talil 


I'  I'siicciallydiinwioi 


W 


Tl 


y  •■•line  hitcs  nil  th,.  Iiiill(ls,"tl 


ii.-^;    next  in  order  of  d 


lis   rcliitivc  ord 


face,  I 


Tl 


"•ad,  iiiKl  hiiiids  Ml 


ci'  IS,  no  (loiilit,  HTcatIv  (l( 


' .Iiirics  on   tlic  otji, 


otiiids  idi 
rurccs  of  III 


■!■  liarts  of  tlu'  1)( 


('  II 


ic  extent   iiiid   severitv  of  t 


sually  inikcd,  whil,.  t|,e  ,,t| 


l-yi'lfiit  n\ he  fact  t 


Illy. 
lat  ill,. 


daiiueroiis ;  the  la 
fi 


ICC 


ccratioiis  arc  fatal 


wound.      I'liiict 


iiT  parts  arc  ejoil 


lire  wounds  are  tl 


itlordi'il    for   ahsorption   of  t 


m   proportion   to  tlie  extent  of  i 


iiiteetion.      In  onU^r  of 


le   virus. 


d.  Tl 


le  animal 


IC    li:..«| 
IC  Mir- 


eat:  tliird,  the  doo-;  f;,„,.ti 


decreasing  .seventy  cniiip  :  first,  the  wo|( 


ro 


111   SIX    weeks   to  t 


1.  other  animals."     Tl 


eonvcyiiii;-  || 
second,  il 


iiioiiths,  and  tl 


Wo  months.     It   niav  1 


icavera 


.ue  period  is  prolijilil 


icre  are  <'a,scs  m  which  the 


•e  proloiin-cd   to  iiioi-e   tl 


I  year  or  eiuhte.Mi  months.      Of  persons  hittcn'l 


iViH>ationlias  apparentlv  la.- 


laii  thiv'i. 


percciitauc   heeome   infected 


cent. 


Th 


acco 


Hit 


neatli-ratc  of  t 


rdiiiu-  to   FI 


II  liv  raiiid  d 


o,i!-s  onlv  a 


led  i; 


orsh>\-  n 


I' 

cer|;iii| 


KISC    IllttCIl    l)V 


ot    more   than    1 


es  upon  tlie  face  are  iiarticnhirlv  di 


wolvo  IS  not  l(..s  than   M) 


Symptoms.     In  the  premonit 


lllU'ero||> 


per  (VIII, 


the  hitcs.  Slid 


lieadach 
and  si 
fc\- 


1  as  pai iiiiil)nes<  , 

d  .1 


|>ry  sta-c  there  isiisiiall 


ir  paricstlicsia.     T 


y  sonic  irritation  ;ii„ 


e,  and  deprosioii  ot  spirits.      The   pat 


■re  i>    loss  of 


ee])lcss,  and   there   is  a 
er  has  lieen  noted  at  this  .sfi 


lent  ma\' 


a|ipi  III,.. 


con.-taiit  sense  of  ii 


lecoinc  very  irriinl,!,. 


seiisihility  IS  nreativ  iiici 


la'f, 


npcinlinn.  ,|ano(. 


IIIL 


^titl 


IIC^ 


'eased  ;  a  hrin-ht  liuht 


ilid  the  piiU'  is  accelerated.      Tl 


ii-hi 


iiav  1 


alioiit   the  throat    iiiiir 


or  a  I, Mill 


le  i;,.|i,-i- 


IC  expressed,  and  the  v 


eli's,  and  shuht   ditfici 


noise  IS  verv  ,h«i 


Jieriod  of  excitcnieiii— tl 


oi 


ee  is  a  little  liiiskv.      In  i| 


ilty  III   >wall 


IV"- 
iiwill" 


afil 


rent  stiniiilant- 


lere  is  oreat  restlessness  and   I 


)f  a   verl 


)al  siiuo-cstion — will   cans 


a  .sound  or  a  draiiiiht  of 


le  secoml  stau' 
iy|ieraslhe.Ma.'    -.V 


■c      III,. 


I\ 


iiir,  or  the  mere  as 


.viiiptoiiicnnstitiitcs  the  most  distrcssinn'  t 


e   a    violent    retlcx 


ociniioii 


P"-^"!-      Ill    man    ilij. 


which  affect  parti 


iii,trly  painful  and  a 


eiihirly  the  miiscles  of  the   la 


catiire  of  themaladv.     'j'l 


when  the  iilottis 


lev). 


Ai 


lecompanied    liv  an 


ryiix  and   nioiiih,  an 


iesh:i>iii 


s  IS  widely  opened  or  traelicotoinv  has  I 


intense   .M'lisc   of  ,] 


.v.-piiica,  ,v,p 


iiiiisclos  o 


ly  attempt   to  ta 


i<e  water  is  as.sociatcd 


las  liecn  pcrforiiieil."  ,  ||, 


This  it  is  which    makes 


pharynx  and   larynx,  and  o|'  the  el 


Willi 


painful  spas 


given  tl 

tioii  coiiviilsion.s,  as  tl 


tl 


evators  of  the  h 


Hi  name  hydropholiia  to  the  d 


i;   patient  dread    the  V(  rv  siu'lit  of 


m-  i.f  tl 
\'oi,|  li,,||i 


lacai  svniptoiiis.     I 


icy  may  lie  called. 


ist'iise. 


r 


water,  ail, I  Im- 


lese  inspiratory  and 


11  the  intervals   li 


arc  .■sometimes  associated 


lli'Lllll 


•initeijuiet  and   the  mind  unclouded.      Hall 


let  ween    the  attacks  tl 


Willi    lii;|||. 


le   patient    iikiv  Ii, 


j)re.<ciit,  not   iiitrcijiiently  associated  with 


lii:i\   111- 


in  tl 


10 


and  ind(.e<I  i 


room.     He  vervVarelv  mak 


may  he,  however, 
the  muscles  of  tl 


nay    iie  particiilarlv  anxioii 


iieinations  and  delusion> 
lie    idea  of  the    |)re>ciicc  ,i|'  a   ,1,,^ 
le  all, 11, lam, 


iny  attempt   to  injure  t 


occasional   fits  of  fu 


lo  avoid   hiirlinu' 


aii\-on,.. 


lie  saliva    IS   iisiiallv 


le  larynx  and  phUrynx  odd  .sound 


I'l'iiis  iiiania.  and  in  the  cm 


ll,'lV 


'iwiiiir  to  the  difficiiltv  th 


aliundant  and   tenacii 


itraiii.iii  ,if 
are  occasiomillv  mnivil, 


fins  stai. 


IS  iisiiallv  el 


patient  has  in  swall 


IS,  and   flows  from  tl 


•  wiiiii  il.     T 


may  lie  afclirile  llirouiihoiii. 


evatcl,  and  may  reach  from  lUll-^  to  !(»;!'.     'j 


le    I nil, 

le  temjieraiiirc  in 


lie  (vIlr.M' 


tl 


In  add 


Itloli  to  tl 


icre  ma\-  Ik 


le  local  spa.-nis  of  th,.  rcspiraii 


a  day  ami  a  half  to  tl 


convulsive  seizure-  of 


"111  and   dcLiliitiiidi: 


wliicfi  the 


iree  (lavs   this  is 


a  tetanoid  character.     Afi 


sciousiie,. 


pasiiis  no  foiiu'cr  oci 


ur. 


■^ilccecdcd    liv 


^s   ,i;radiiallv   supervenes. 


le   patient    I 


.rlr-. 

er  la>liiin'  f;,r 
lie  paralytic  M.ii;,.,  in 


iechlc,  and  death  occurs  1 
stau'cs  arc  aliscnt  as  a  riih 


le   heart  s  action   u'cts 


leconies  (|uict,  and  iii 


»\'  svncoiK 


nm- 


more  and  imiiv 


pe.     In  aiiimals  the  ]>roliininar\  ami  ruri,iii. 


he  so-called 


duiiili  raliii" 


ami  the  paralytic  may  he  marked  f 


III  n 


laii  the  paralytic  f.rni  is  exlreinel 


roiii  ill,.  tiiM, 


\     lill(.|llM- 


I  TMKXT. 

(yii.     Wounds  iiliMiii 

T  (if  (l(>iiTC('S  of  liii.v. 

■I'  piirts  of  the  li.nn 
"1  'lie  fiict  thiit  ii„ 
'■  I'.'irts  aiv  clnil    ,| 

Ollllds    lllV    tllC    ll:  ,-1 

i'  extent  of  the  Mir. 
inial  coiivi'viiiM  ii,,, 
III'  wolf;  siH'ond,  lii,. 
;•(■  period  is  prohaMv 
to  nio;v  tliiiii  ilir,;,. 
i))|)iiiviitiy  liisti'd  i;,|' 

<lo,i;'S  ciiily  ii    ,.,.|.i.,j|| 

iHiire  tliiiii    ].")  |„.|. 
-.^  than   4(1  ncr  <•,  in, 


"lie  irritation  jiImhii 
'  i>  loss  of  a|i|i(iii,. 
■coiiic  very  irriialil.- 
ii.ii'  dani^cV.  Siinh, 
iited.  Till'  iivi:(.i:|| 
oisc  is  very  di>iiv„. 
"I't.v  ill    >\'vall(iniiiM 

second  sta.;:c  ill,. 
lerasllu'sia.  "Aiiv 
lie  mere  associaiid'n 
^iii-  In  man  ihi- 
lady.  'l'lu's|,MMiiv 
Houtli,  arc  c\(v,..|- 

of  dyspiiicii,  i.\i  |i 
performed."  ,  i|,,i. 
if'iil  s|iasni>  (if  ill,, 
iif  llic  liyoid  Imiii,.. 
of  water,  and  h.^ 
itory  and  di-jmi. 
iieialcd  with  iniin- 
e   palicnt    ni;iv  In 

||elusinn>  iiin\  iir 
presence  III'  11  i|,,^ 
I'e  tiic  allriiiliiiii. 
X  anyone.  Thin' 
tile  contraciiiiji  u^ 
"i.-ioiially  iiiirivil, 
t'i'om  (he  liiniiil]. 
he  lempeialiiiv  in 

'*■')'.       The  cilii',,. 


i!'liitition  niiiM'lc-. 
•Vflcr  ia.Miii:;'  t^r 
ira lytic  ~hiM,.,  i,, 
uiet,  and  iiiirnii- 
more  and  inmv 
inary  aiei  iiii-inii- 
'il  from  I  he  lir-i, 
xlrenu'lv  inicnin- 


:i 


IXFECTIVi:  h'SEAsi:. 


iii'Hi.  tli(ni,^li  ciws  oi'  ii   ||;iv,,  ] 


21' 


ii'l'iiii  liiiraplci^iji,  ;ui(l  wit 


"••■11   iv|M,rt,.(|,  ami 


Morbid  Anatomy.     Tlic  v\nv\ 


1  Miiiptdiiis  rc,-ciiili| 


"    Illil.V  .Icvclolicd    will 


will.  IlIlS    {■Xilllllllcil   I) 


•iitmiis  lit'  vascular  distiir 


il.-CS,    ('(11111(1 


li'sKins  arc  in  [| 


iii.ii'  acute  ascend 


I  it 


rt,c-lik 


lailcc;    I 


iiiorlnd   chaiiucs   in 


II'  iicrvdiis  s\>i( 


iiil;'  nnclitis, 
ill.     (  ■ 


lilatat 


e  <;oi'))iisclcs  iifoiiiid  tliciii  and  in  tl 


'I'll  (if  small  vessels 


■vKJeiitly  fornied  diirinu'  lifl 


le  tissue 


*>1CIII.         (i()\\,.ly_ 

I  lic>e  were  indi- 
acciinnilalidns  df 


iiv  nicl  witli   111  vari 
till'  iiiediilla  (il)l(iimat 


"ii>  I'arts,  especiallv  ii 


and  niinnte   licniorri 


'•lilts  in  small 


lauc: 


'J'l 


Ves- 
lese  cliaiiu'es 


ill  llie  iiiediilla,  liet 


I,  and  the  spinal  (Mird.     'j 


1   tlie  cortex   of  the  liemisnl 


ween  tile  emiiientia  teres  al 


nev  are  alw 


jiynniiids  M.iu,  and  especially  in   the  nei^hhorlK,:,,! 


al,  and  spinal 


ihdiit  the  vos.sels 
(1 


aecessdrv  nuclei.      T 


didve  and  the  d 
if  tl 


plleres, 
i.v>  iiiii>l    inlense 
■eii.-salidii  (if  ih,. 
le  piieuiiKiiiasiiic 


IS  a  verv 


cull 


iHcUdus  change.     '| 


It'  aecuiniilatidiis  of  |,.|| 


ciievte.- 


Y'li  ;iH(l  may  he  s.M.nmenins  as  t(i  fill  up  the  wh,',le  sp 
<lii;iili:  they  may  extend  aldiiu'  the  vessel   \ 


even  iiiiss  intd  the  ad 


if  cnrpiiM'les  than   n,,,  mal 


adjacent  tissue.      Tl 


iiciiM'  masse.' 


•  nil  111  places  il 


le  nuclei  cdiitaiii  a  imicl 


niTiiuiid   the  diit( 

pace  within  tl„.  lynipatii 

lance,  and 


"!•  a   cdiisiileralile  dis 


iU>-C( 


\\<. 


arc 


ihc  llllrralld: 
(lie  voxels  with  I 

mailer;  in  this  the  cliai 
:iitlHiiit;h  thev   involve 

tciisc  a,-  t 


since  the  cdrpii.-cl 
•  ■•(,  '  iniliarv 
ii>uallv  miK'h  si 


ay  may  he  a-.-reoaled  and 


es  liia\-  lie   i 


I  lai'M-er  niinil 
fir 


aliscesses. 


e^arded  as   idemi 


i.uliter,  ai 


eiicocytes  and  to  an  in 
i.tii's  are   usiiall 


are  confined  t 


•■I'fase  III  the  niiml 


ley   involve    these    ii 


"  eoiistitute  a 


I    severe  fir 


y  .UTcater  th;       in    tl 


ler 
111 


eal  Willi 

pinal   cdrd 

"  eneriistatidii  df 

nher  within  the  univ 


III    till 


ins 


If  Uillle  eoliimi 


a  ca-c  has   run  so  r 


''"'"ilitioM   praeticallv  of  aci 


ie\-  nia\'.  111 


'I":'  :•   '•oui'.se  as  to  he  final   in   || 


'te  myelitis.     ]■; 


"eiij,   lie  .vo  ni- 


riiaii-c^  may  he  ediispiciioiis.     The  '  niiliarv  al 


III  the  ciii 


itllcr  ;i 


Itcrati 


On  the  other  hand,  tl 


an  animal   iiioeiil; 


Ills  than  are  com 


ic  eenlral  iierv 


nve  days  siicl 
'  are  verv  sel 


len 


ited  with  ral 


mill,  'itter  death  f 


'ins  svstein  1 


Veil  wl 
1  myelitic 
ddin   seen 


.-v.-lciii  Iciicdcytnl  intiltratidii  has  I 


dues,  as  well 


i''"ii  iisphxia,  and' this 


Tl 


Klilne\- 

III  the 

iiiaifir  which  the 


IS  lieeii 
le  miicdiis  meiiihrane  (if 


i'-'  in   man.     ( )iit-id 
d 


nay  iJi'i'seiit  111 


even  in 


t'  the   iierv 


(lUs 


tlu!  stdiiiat'h  iidt  iiif 


;;•■■','"   tl'<'^=il|varydandsaii(l  in  th 
pharynx  is  ciumt'.'^ted. 


tile   larvi 


IX  and 


animal  has  eat 


reipienilv  cdntai 


'"l"iiinial  iir  thiiracic  viscera. 
Diagnosis.     'I'l 


en. 


Tl 


ns  straw,   In 


ii'i'e  are  no 


IV,  and   f 


orei^i'ii 


tnnii  "ihcr  or: 


ami  (T.iiiip.     In   tetai 


i.fi'<'  1^  rarely  any  diftic„ltv  in  .li<ti 
inic  aflections  of  tl 


le  nervous 


IH'eial   eliaiiu'es   in   the 
ni.-ui-Iiiiin^  hydrdphdhia 


HIS 


pasnis  of  the  deuhiti 


;■'''■'■ '"■'•asidiially,  l.ut  the  character  of  tl 


ysteiii  asMiciat 
tiiiii  and 


clapvil  liet 
iiiid  the  iihs 


a'  Wdiiiid,  the  si 


'■«' the  symptimis  dev.'ldp,  the  presence  of' t 


ilisence  iit 


lii'eatt'st    liahilitv  t 


•n.v  aversion  to  liipiid.  render  the  d 


<'<!  with  spasms 
inspiratory  niiiseles 
I'li'i  lime  which  has 
ipisthotoiios, 


llldl 


la,  wliici 


'I  error   is   in   tl 


risiiiiis  and 


laiiiiosis 


>iiiiiilalc  the  true  disea.se.      A 
Mi|i|i(i-r(|  to  he  so,   mav  di: 
"her,  ^vmptomsresemhiin 
iii""dv.  (•(iiistaiitl 


1  IS  a  neurotic  or  hvsterical 


ic  .so-called 


Clear. 


pseiidiidivdrdiihdhi 


nianifestatidii,  and 


1' 
nia\-  c 


'H;rvi.iis  person  hiiieii  hy  a  dou.  either'ral.id 


a,  or 

(iselv 


play  within  a  W 


'li.vdrojihohia.   He  In 


u  nioiitl 


or  even  several  v 


•■'■'''■'III  '"  .iiii  mad.     Tl 


Jieaks  of  his  al; 


irmiiii 


•laiiesirritahle,  di 


ear.- 


pressed,  and 


'•■re  may  he  hy.sterieal  paroxv 


conditidii,  and   insists  that   I 


::;''';,:-';-i'ietodri,ii._and'shu.id;.:;;x!:s 


■ins,  111  which  1 


MVcIv  at 


'!•■*  tliniat,  and  I 


U'eiinies  enidt 


It  ( 


le  sav.- 


i"'"l;M|iei'swere  full  of  the  details  of  1 


idiial 


A   f 


II   Iliinl 


"."'■'I  NIC,  who  jiad  heeii  I 


asteiirs  treatiiiei 


ew   vears  a"' 


rrasps  eoiivul 


'",  when   the 


slill   :d 
lie   had 


ntten  a  year  nr  more  previiaislv  I 


It.  a  yiiiiiiii-  man  o 


on- 


>i''e  of  hi.,  felldw  clerks  had   joked   I 


y  a  dd(i-  whieli  was 


ii'aihiallv  1 


'•■'•o'I'e  very  much  alarmed.     When    [  s 


iim  upon  thesuhjeet,  and 


^'J'''tly  excite.1,  had   pains  in 'the  th. 
'"^•"'I'tiiiu'  to  take  a  o.|ass  of  water  I 


ii'iial,   didieiiltv 


iw   him    he  w; 


le  would   I 


111   >walliiwinu',  and 


H'i'iinie  -reatlv  excited   an 


I 


U I 


I 


] 


hi 

I 


^18 


alai'iii'. 
sis-c(l  ), 


xrnvors  nrsiusi-js  and  their  mEiTMENT. 

1  Wdiild  have  a  |tsl'^l(l()-(■(lllVlll^iv(■  attack.     Tlicsc  syni| 


I  coiiplo  of  weeks,  and   iiltiiiiatelv  vieideil  to  treat 


timi- 


eleetricity.     There   have  l)eeii   instances  piiltlisl 


nienl  with  si 


nil' 


led   as  lvss((i)holiia  in  wliiih 
M'conii'  mure  f're(|nent,  and  the  jiatien't  lias  died  exliaiisinl. 


iiese  seizures  have  1 

Gowers  hdhis  tiiat  llie  niajurilv  oi'  these  c 

remarks  (in  this  pdint  are  wort'ii  ((Udtiny:   "  Tliere  has  more  ot'teii  1 
deney  to  regard  tlie  jreniiine  disease  as  ima-:inarv  tliaii  to  mistake  t 


uses  are  in  rea 


litv 


jreminie,  and 


genuine.     This  tendency  is  es|icciaily  in 


for  tlio 

not  seen  tlie  case,  w  ho  d 

case: 


rked 


)een  a  Uw- 
ies|)iii'j,,||. 


It  is  not  certain  that  deati 


o  not  scniple  to  east  (haiiits  on  tlie  nat 


iiiioni;-  critics  w 


ho  I, 


lire  of  even  liHal 


Xowadavs  tlie  test  of  the  nature  of  a  fata! 
inoculation  experiments  are  (iiiite  coiiehisivc 


li  has  ever  occurred  fnnn  mere  Ivssoidiol 


'I'll' 
ease  can  he  readilv  ma<le,  as 


III. 


Dull 


I' 
111  particular,  has  ealleil  attention  to  a  nuniher  of  d 


symptor.is  of   hydrophohia    niav   occur,  and   he   h 


iseases  iii  w  j 


t 


lorougii   and  svsteinatic  exaininati( 


)f 


IIS   rightly   urged    a    ii 


proiioiincing  upon  the  irregular  symptoms,  which 
to  follow  the  hite  of  a  doi;- 


patients,  and   iiicater  cauti 


on   111 


111  nervous  people,  are  ;i| 


Treatment.    The  local  treatment  of  tl 


le  wound  is  imiiortant.      If  on  a 


11  ligature  should  he.  jilaeed  above,  and  it  should  then  he  thoromd 


I  zed 
at  hi 


A  I 


iiincli  of  lio|;ted  matches  will 


liiiili. 
ilv  caiiiti- 


!• 


Iiou 


Id    I 


Strong  carholic  acid  or  nitrate  of 


rve  the  purpose,  if  nothing  heii 


silver  mav  be  used 


)e  eiieoiiraij-ed  to 


xcision  of  the  wouinl  is  al; 


aid   it  should   he  kept  open  for 


o  recommended.     When  the  disea.se  has  d 


I'l'i- 

:ie  v.Miiii,! 

-oiiie  liiiic, 


r 


the  jiatieiit  should  he  ke])t  absolutely  (piiet  in  a  darkened 
a  couple  of  nurses.     There  is  rarelv'anv  nece.ssifv  for  rest 


(■vein 
room,  ill  char: 


;v  (if 


raint,  and  the  plu- 


Hciaii  can  assure  the  attendants  tliat   there  is  no' risk  in  their  diitie.' 
is  not  a  single  instance  on  rec(n-d   in  which  the  disease  has  1 


Tl 


ICIV 


1V( 


patient  to  nurse.     As  a  rule,  tl 


IS   lieen  traiisiiiiiii 


le  patient  is  readilv  controlled,  and 


not  re(|uire  to  be  forcibly  held  or  restrained.     X 

to  force  the  patient  to  drink  or  to  eat.     Sometimes  he  cat 


o  atteiiii)ts  .should  1 


It 


is  .stated  that  the  local  applicat 


throat  and 


tion  of  cocaine  allavs  thescnsitiv 


le  mail 


1  swallow  readilv. 


en 


ibles  the  patient  to  swallow.      If  iiecessiirv.  niiti 


cness  of  tin. 


niay  be  given,  or.  if  the  jiatient  ca t  lake  water  liv  tl 

tious  may  be  given  per  rectum. 


le  month,  I 


'lent  eliclllilta 


ligc  iiin'c- 


There  is  no  medicinal   treatment  of  anv  value.      In  the  viol 


inhalation  of  chloroform  mav  be  tried.     Sloriihiiie,  ehl 


ent 


USUI  tl 


.  1         ,         •  I'        . 

iiiiii,  and  curare  have  been  recommended.     The  latt 


if  from  a  tenth  to  half  a  uraiii 


ciiiar  wcaknci 


repeated  everv  half-hour  until  tl 


lu'omide  III  iMiuir 


I  )>('.« 


er  mav  be  tried  in  ,\ 


lere  I-  liiii> 


I'i;i:vi:\Tivi;  Inocii.ation.     Tasteur  found  that  tl 


cords  of  inoculated   rabbits,  wl 


le  virus  111  till 


leii  preserved  with  careful  anti.seiili 


tions,  gradually  diminished  in  intensity,  so  that  the  fourteeii-dav-old 
igt'r  poisonous.      Dogs  inoculated  with   portions  of  cords  di 


no   I 


pile    jH'crail- 

hvi 


con  I  wii 
■led   ill   tlii.< 


way  and  (it   increasing  intensity  ac(|uire  immunily,  and  are  in  realiu  vairj- 
nated  against  ihe  strongest  virus,  which  would  otherwise  I 

.... 


lave   priivnl  fatal. 
le  long  incubation  |iii'ii 


IJelyiiig  oil  tlie.se  observations  .(nd  on  the  fact  of  t ^  ,.,,„ 

['asteiir  began  the  inoculation  in  luinian  beings  bitten  bv  rabid  aiiiiiial 
what  is  known  as  the  .simple  method  the  individual   receives  an  in 
the  (irst  day  of  a  portion  of  the  spinal  cord  of  a  rabbit  which   has 
serve(|  in  the  drv  air  for  foiirt 
thirt 


receives  an  injcriinii  mi 


cell  (la\s  ;  on  the  sec( 


ecu  days  old,  and  so  on  until  the  cord  of  the  fifth  d 


ind  (lav  a  bit  of  tin 


is  called  the  more  intensive  metliod,  on  tl 


IV  IS  used. 


•I  I   nf 

vJKlt 


lie  inornin:!'  of  the  first  dav  n  i.iiriiini 


f  the  cord  (rubbed  up  in  sterili;;od  bouillon  )  of  the  fourteenth  and  lliiilcciiil 
dav  is  used,  and  in   the  eveninir  the  cord  of  the  twel 


i'c  and   eleven 


Oil  the  .second  day  in  the  inoriiing  the  cord  of  the  tenth  and  ninth  d; 


ill  li 


:iy, 

Ibcil, 


MENT. 


iu'sc  synii)tunis  |i,.|'. 
■(■atiiu'iit  with  st;iii,. 
<.«(>l>Iinl)ia  ill  wliiili 

llilS  (lifd  t'xlliHl>Iri|. 

ty  genuine,  and  \\U 
re  often  heen  a  it  n- 
nistake  the  s|iiirinii« 
ml:'  critics  wIki  have 
iiatnre  (if  even  liual 
mere  lyssopholiia." 
•adiiy  made,  as  ih,. 

)f  diseases  in  w  liicli 
itiy  nrged  a  iiiuiv 
,L;i'cater  eautidn  in 
(lus  jieople,  arc  a|i| 

ant.  If  on  a  limli, 
tlioronghly  caiihi- 
if  nothing  heiii  rjv 
used.  The  viiimi 
pen  for  some  lim... 
•ea.-ie  lias  develii|i|.|| 
room,  in  charge  nf 
•aiiit,  and  tlic  \A\\- 
leir  duties.  Tliciv 
-  licen  transiiiiiicil 
jntridied,  and  dues 
:s  should  he  ni.aiir 
11  swallow  reailil\. 
•ensitiveiios  .if  ih,. 
,  nutrient  eiieiiia;;i 
miuith,  large  injir- 

violent  spasm  tlic 
,  hnnuide  nt'  pn(ii>- 
y  he  tried  in  doso 
until   there  i<  iiins- 

I'irus  in  the  -pinal 
antiseptic  precnii- 
i-day-ujd  cipril  \\;\< 
■ords  drie(l  in  this 
'e  ill  reality  viicci- 
lave  pro\-eil  fatal. 
inculiatiiiii  jierinil. 
ahid  aiiiiiia!-.  In 
■es  an  iiijeeiiiiii  nn 

licll    has    heell  |il'i'- 

a  hit  oi'  tlii'euni  iif 
is  used.  In  \vli:it 
first  day  a  hni'tiini 
itli  and  limieciiih 
lid  eleveiilli  ii;iy. 
iiiiith  da\  i^  iiM'il, 


INFECTIVi:  DISEASES. 


219 


s.nr<  IS  l„.i.nii..  usi.allv  with  tl,,.  ,.,.nl  „f  t   ,.  '    "  "'"'•,  •  '  '"'"   "  "'"■ 

All  fiiornioiis  ininilxT  ((hm,  ]-SN(i  to"  .iMnii-M-v   i    is.,.    ,.  ,, 
"""  '^VM.M■nlulsn,l,i,|,orsul,,H.s,.,lt.>lc-         ;  -I     '  I      *'  V'^'"'  '"■'■^""^> 
isiii.itc.     Of  tlu'so  o,  Iv  72    .  m   ,  i,         \  '"■'■;.' ''■'■^'"■■'  '"  '!"•  l'".-^t..ur 

7:!;.  j"'''^i"-''i--aHvnor'.,::':;j;;;;t':i::." 


Ii 

III 
lilt 


••^  nics(.aircai'enillys..])i,nii.d. 


u  Mil,.  III,.  ,,r,.v,.ntiv,.  iii,„.,ih,li„„  is  M,„  invui.   ,N  ••  7'l*"''.'";"- 

'IV  iialural.sin..,.  manv  |.,.rs..i,s  ani.lv      .,.         ■      '    r"''<7'^<"'-  =i^  ni,|..,.,|,  i, 

v  :niii.ial,s  u.Hlu„l.t...llv  mCI^^^I^'^':!    ''^V'^V  '"  '"''^""^  ''""■" 
■VMtIv  l,.s,s,.n,..l,  an.l  in^onu.  v,..;.    •  ^"■.'  ""<;>"  ''v  tl.-  .im,.,ilati,Mi,  v,.rv 

■'-"■;'  i"  "I-..:  ,1...  na,.,",^' ;    ;:.::•;;:;• ! ;:r- -v  >^"i: -f' ^>'»-*  1-.-... 
'.-' Hi,.,  is ,.._  i.;2..i/-;;;;;-^. ;::;;. ^^ 


I 

t;'l',.i 

ilVi 

;i 
mil 

llin 


Definition 

lllrlilli;'  el 

Etiology 


A 


TETANY. 
/"!';:^:r"'.l'.''"^'''''''"''''''''-'^<'t<''-!^<''l''vl>ilat..ral 


t'llv  the  oxtroiiiit 
Til,,  disease,  dcnrs  cliieflv 


tiiiiic  siiasni-: 


III  vmiiii 


'■;!l.'''i''''''i'''fi'<.MiHMitiy  tliaii  n.|iiai,.s.    ( )f  lOi 


'lilli'i'iiil  s,iiiiv<.s,  7()  were  in  maii.s 

^'  ;'"l";i;'Miil  con.iiiions  xuu\vv  whirli'tiio'llis 


I'ci-soiis,  and  attacks  males 


i-iscs  a.iii.ctcd  l)v  ( 


iiiid  (Ki  ill  females.     Tlie  i\ 


'(»\v,.rs  fV( 


nu 


'/.   Ill  I'lii 


-iirii  as  iliarrhiica. 


Idrt.n  associated  with  tl 


'i'l 


ic  c 


"illi  ncl<(.|s,  is   rcNiirded    I 
-i'||iiciicc  of  the  fi'ver.- 


irpopedal 
>v  soiiic  a.- 


le  (Ichiiitvof  cj 


:eas('  (lev. 


"Howum  arc  the 


inmic  cxhaiisti 


-|)asiii,  so  <Vc(|Uciitly 
I  variety  of  tctaiiv.      It 


ii.i:  maladies, 
leen  in  conneetic^n 


occurs  as  u 


Nirliciiiarl 


y  III  certain 


;.;.">•  cases  have  ,levelo,,edaih.r,v,d.oidti:; 


' eel  ion  with  hr,.n'na 


'■P"l''>Mics      A  feu-  typical  instances  | 


pregnancy  ami  lactation,    'l 


I' 
lave  occurred  in 


A.  A 
lliyi'iiji 
rliiiic. 


iiitilie  coniractioii  of  nui 


ii'iiiiirkahle  a,ssociat 


It 


lam 


Thirt 


ion  exists  hetw 


iiiiiv  recur  in  sm 


ronsseaii  called  the  dis 


ease  the 


<'en   easLs  f.ilowed    7.S    tl 


ecu  tetanv  and  tl 


cessive  preunanei. 


^i';  of  which  prov,'d  fatal.     It 


'III-  1-  ili(.  mo 
:iiii'iiiil>  is  also  toll 


serious  f( 


fill 
"■'II  of  the  (lis. 


IMS  total, 
J 


lyroidi.ctonii 


le  r(.moval  of  tli 


es  1 


n   Billrotl 


1  .s 


iit>t   partial  extirjiation. 


'Mil  a  cas,.  reported  hv  .J 


'"W«,"ll>vtc.tany.    Tetanv  and  nivxied 


'''ease.     Kemoval  of  the  thvroid 


i      !■ 


Tl 


le  (iiseast 


iimes  Stewart. 


ema  mav  lie  as 


in 


sociateil 


M>,.as,.  o,.,.nrs  ni  ep„|,.n.ic  f;,rm.  part 
iiirni'i-  t  If  unit., 1.  ......,ti.        I-.         '. 


"i'"l"'  diiriiiir  the  wintei 


III  j.s, 


I''  yiMlllo'    III,. II    (if    ( 


mid  I,s7(i,  and  a 


months.      Kx 


'•'".'"'•ly  "11  the  continent  of 


•■'I'e  I'ai'e  in  th 


le  work 


I'eceni  (.pidenii 


teiisiv,.  ( |ildeni 


les  oc( 


A 

>liiii 


IS  f<irin. 


"ly-  cla.-^se,. 


e  (lescrihed  hv  von  Jackscl 


'iirred  in  Paris 


usually  with  sliiiht  fever.     Fatal 


I  occurred 


cases 


ml,  lastlv.  t,.i 


iiiy  has  heen  met  wit 


piii'tieularlv   in    tl 


Irillh  is  Very  apt  t 


le   ,,is,.s   ii 


1  'II  connection  with  dilat 


I    winch    lavai;e    has    I 


iti<in  of 


Im.  I 


niiv,  iiimI  i,  j,., 

liciliil  s 


".'•<''i;  in_coiiia.     .\  f,dl  record  of  tl 


•",'.'"   ll"'   I'aris  Thesis   by  \ 


not 


rurre,! 


antler. 


In  A 


>een    practised. 
w  ea.ses  to  l,s<)2  „ill 


piis'ii  he  included  the  di 


111  epidemic  tonn.      If 


.America  true  tetiuiv 


iii\\ev(.r,  ea.ses  of 


■"■■^c  IS  not  iiifr(.(jii,.|ir,  and  (;riflith  1 


is  Very 
earpo- 
las  lie,.]] 


TmiisiutioiiH  ,jf  tlio  As 


^ssofiutioii  of  AiiKTiouii  I'll 


.vsiciuiis,  vol.  iv. 


It 


i   % 

I  :i; 


22(1 


XJ:i!Vnr.-i  D/sK.lsh'S  AMI  Til  III  i;  TliEATMHST. 


llilf  u 


II I 


•I   tViim  I  lie  iitcriilmv  72  c 


ascs,  1 1 


111  tiir  iirtc'cliiii 


If  cindiiiiil  -.yiniitonis,  is  rarclv  seen. 


1    IM   iliilllts,    Willi 


Symptoms.    Tlic  t'ollowiim'  WwV  statcinciii  dl' 


waids  in  1.S1I4  will   illustrate  soiiu'  of  tl 
111'  tetany  wliicli  recurs  witli  i)re;;iiaiicv 


a   ease   w 


liici 


1  was   III 


le  reiiiarkalile   cliaraelers  dI   the  i; 


Mis.    I 


cij  ihii'tv-tl 


iree   years;    iiia-i'ied   at   eiirliteeii ;   first   eh 


iiiiieieen    iiioiitli^  aflerwanl,  and   a   second    child    two    v 


While  three  liioiiths  |)l'ei;liant  uiti 


eafs  after  the  II 


I'    , 
■lied  and  felt  tired,  and  tw 

-yniptonis  continned  until  a  short  time  hefore  h 


i-i. 


e    1'  tlire 


the  second  child  she  noticed  tliat  her  h;iii,|. 
e  times  a  day  would  uct  i|iiite  stiff.  Tl 


much  hetter. 


he  remained  free  fi 


er  eoidiiiemeiit,  when  sin    fell 


labor,  when  thev  returned  iind 


the  cramiis  until  the  ninth  da 


were  more  violent.     Not  olilv 


were  til 


•loseil  in  eram|.,  liiit  the  feel  would  aNo  di'aw  toucther.    The'attaei 
acc(mipaiiiei|   hy   niiieh   pain.     In  the  intervals  the  hands  and  feet   I 
usual.     The  attacks  recurred  for  five  months  and  then   disappeared  f 
months.      In   Novemher,   1.SS2,  after  e.\|)osure 
appeared  with  greater  intensitv,  and  earlv  in  D 


y  nil, 

e  liiiiiij 


were  ||u| 

■ell  ;i- 


er  exiiosure   in   the  snow,  the  si 


or  iwi 
lasiii-  iv- 


severe  attach  in  which  the  hands  were  closed,  the  ell 

held  close  to  the  body.     The  spasms  in  the  hamls  did  not  relax  t 


ecemlier  she  had  an  iimi- 
lows  Hexed,  and  the 


fiv 


\n   her  third 
e  months  she 


pi'eL;nanc\-,  wine 


had  1 


lo  cram 


ps,  hut 


h  followed  in  a  short   time,  di 


or  a  \\i 


iriiiu'  tlh    lii 


laily.     They  apiin  disajipeared   just   hefore  I 


in  the  last   four  months  she  had   iln 


IV,   and    the   fourth   iirciii 


ibor.     She  did  not   niir-c  ih 


IS   lielo 


.iiiiancy   followed   m    tour   month 

cramps  t;)r  the  first  four  or  five  months,  but  thev  recurred   ; 

the  last  four  months.  While  in  labor  she  had  a  very  severe  attack 
four  or  five  hours.  She  afterward  remained  free  until  the  ninth  (!;■ 
she  had  a  very  severe  attack. 

In  her  fifth  iirepianey,  which  tiillowed  in  f 


ne   iiiKi   ||M 


re  d 


iinii:: 
a-iiii" 


i\-,  ^^  III  I 


at  intervals  throui^hoiit  the  entirt 


|>eri( 


ive  months,  the  spasms  oimmiv, 
In  her  sixth   preuiiaiiev,  whicj 


beiian  eighteen    months  after  the  bii-th  of  the  fifth  child,  she  was  fre 
the  first  five  i iths,  then  the  cramps  returned  wor.se  than  ever. 


e  illinii:; 


ami  leu's  W( 


luld  net  stiff  and   iiainful,  and  she  had  for  the  first  t 


The  I 


le  liaiiil' 


the  larynx.     Diirini;'  the  last  i ith  of  tli 


ime 


'I  hey  recurred  a^ain   on   the  ninth  dav  afi^  r  J 


IS  preirnancv  there  were  no  all 


ii'i 


h 


ler  .seventh  preiiiiancy,  nearly  thr( 


iiior. 


I'^'om   this  t 


line  liiilil 


irs,  ,-lie  \\,is  well,  except  at  abiiiil  iIh' 


time  of  the  menstrual  periods,  when  she  alwavs  had  the  spasms 


II  her  seventh  pre^iiiaucy  the  atlacl 


for  a  lonu'cr  period  before  lai 


ks  occurred  as  usual 


but  si 


le  wa~  iii'titi' 


)or. 


Since  ,Iuue,  l.S!t2,  the  date  of  her  last 


i-t  ( Iinemcnt,  she  lias  had  the  ,•111 


at  intervals,  usually  about  the  time  of  the  menstrual  period. 

The  patient  is  a  youn-i-lookiuu'  woman,  well  nourished,  a  little  pale.     Tl 


or  nerves  wa.s  verv  yreat,  ih 


e  >llL;lili-t 


mechanical  excitability  of  the  mot 

taj)|)in,u-  ill  the  course  of  the  facial  nerve  was  sutfieieiit  to  pniduce  <Miili:i(ii,i„ 
of  the  mu.scles  of  the  face  on  that  side,  and  the  electrical  reaction..  u>  W 
meiitioned  hereafter,  were  present  in  a  tvpical  manner. 


Tl 


le  onset  of  the  intermittent  spasms  mav 


as  a  rule  there  are  slight  feel 


if  iiunil 


le  siiilileii   and  iinexpr 


mess  or  pain  in   the  extreiiii 


il.  lull 
ii-.  Ill' 


■e  usiiallv  alteclnl  lir.-l. 


a  feeliny  of  lassitude  and   heailaclie.     The  hands  a_ 

and  the  spasms  may  be  confined  to  them.     The  eontraetion  beuiiis  in  ilic  in- 

terossei  and  the  smaller  muscles  of  the  hands,  which  feel  stifi"  and  nai d. 

and   L'^radiiallv  assume  what   has  been   known 


IS  the  writiuii'  post 


fin-ers  are  cjiKriy  pressed  toi:(>tlier,  the  thumbs  adducted  and 


mv. 


lie 


airainst  the  index  fi 

neath  the  finder-.     The  hand  itself  is  wnerallv  flexed,  and  t 


ii^-ers,  or,  in  children,  not  infre(|Uently  flexed  liL^hi 


pres.i  ,|  iiriiiiv 


V  lit.- 


held  in  flexion.     In  children  the  arms  are  not' iufreiiiientlv  fold 


le  eliidW  iil^ii 


ivcr  liu' 


".i//;.v7'. 

•tiiin  ill  iiiliills,  Willi 

wliicli   wiis   ill   iMV 
iraclcis  III   ilic  Inijii 

II ;  iii'st  cliilil  liniii 
cars  after  the  lir,| 
ticcd  that  Iicr  li,iii,|. 

ft   qllitl'  Stitr.    'Iliisii 

iiiriit,  when  >lic  ti'lt 
the  ninth  ihiy  ■aWvy 
Illy  Were  the  IkiihU 
he  attacks  wciv  nui 
(Is  and  t'cct  fell  ;i> 
lisa|i|icarcil  i'<<y  lu,, 
uw,  the  s|);isiii>  IV- 
c  liail  an  iinii-iiallv 
Icxed,  and  the  aim- 
)t  rehix  i\>v  a  wnk. 
le,  diiriiiL;-  thi  IIim 
iitiis  she  had  lli.iii 
did  not  iinisc  ilii> 
tlis.  She  had  ii., 
I  as  hejiire  dili'iii;j 
I'cre  attack  Li-iiiL 
le  ninth  day,  \Uh  i 

lie  s])asiiis  iicciiirivl 

|)re,i;naney.  w  liirh 

die  was  I'ree  ihii'in- 

I  ever.      Tlie  haml- 

first  time  spa-m  ni 

fe  were  no  allack-, 

111!   this   time  iiiiiii 

'xee|)t  at  ahniii  iL 

lasiiis. 

lint  slie  w;i>  lii'iii, 

las  had  tlir  aiiaiL- 

)(h 

a  little  pale.     Tli. 

i'reat,  the   >li;;llli-l 

riidnci niraciinii 

id   reaetioii,-.  in  \\ 

id  llllexpeetcd.  Inil 
the  extreiiiilic-.  nr 
iially  alH'cii  il  liiM. 
n  heii'ins  in  ilir  in- 
stiH'  and  riaiiipi'ii, 
inj:  piisinrc.  The 
and  ])rcs,-id  iiniiiy 
•  Hexed  ti'jiitly  ln- 
iid  tile  cIImw  al-o 

■|v  folded  over  till' 


!  i 


iM/:f  T/vi-:  itisi:.isi:s. 


221 


I'lir.l.        Ill    lllc     I 


'•«'■!•  •■XllVillilic,   ill,.    (|,,x 


Ijnll 


i-i.i;  III..  tn,.sMn,iiu.|y  ||,.x,,,h„„|  ,!„.  ,;,,,,  III  ,, 


">•'  of  I  III.  i;,,|  ,111,1  , 


riif  tlii,L;li  iiiii<c| 


iliv  lt'>-  coiiiiiioiily  illltickcd.    '  I 


•'•■'  IMV    niivly   ilivnlvcil.       'ri 


IC     tillllK',' 


"<•>  iH'c  III  tiiiiic 
"■||iiini>-v:inis  |)n^i. 


!>'    Illll>c|c,  of  till'   I 


H'l'  tllllj 


tlir  :ilii;'lcs  of  tl 
iiivdivcij,  hilt  llicr 


''•  '""."ilMiiv.lniwiioiii.     Til.,  tniiij, 


'iH.v..n.  ,,,>,.,  Ill,,,,,  may  I,,.,  |.iM,MK,ni,| 


IML 


iMVcivspa.Miitlif  Ihoiiix  iiiiiv  III' I 


;i::;r";:;',"S' "■■-;"  "'■'^i'->." -.;::'.v:i 


III  nicilthlliu-. 

lllllliMIS. 


ri 


K'  -Kill    of  the  liiiii(i>  ainl  t 


IK' >|.iisiiis  III','  |iiiroxv.iiial.  coiiti 


li'Mir  or  more,  occiisioiiiillv  la>tiiin'  tl,. 


I't't    I-  Miini'liiii 
iiiiiiio-  fi-oi 


i<  iiiiiscli's  arc  \i'i'\   rarch 


ir- 

CllltV 


'x«'  ,aii(l  lii.'i'..  may  h,  .-li^linlitti 


•■■^  ii'iiM'  and 


O'llC- 


niir,  |iaiMl('-s 

rlillli|)-lik('. 

mill  ill  cases 


Itiit 


several  ila\-.     Tl 


'I  :i  i''U   iiiiiiiiies   to  ai 


'I'l 


Mlieii   the  sjiasins   are   iiilense'il 


I''  i''iiitnietiii'e  1.-,  j|«  11 


If   lilillil  is  el 


siieiatcd  with  dilalcil 


I'ar,  c.\ee|it  in    || 


1''  |iaiii    niav 


"•  '■xirciiii'  d.l.iliu   of 


i|iiriil  areoiiipaiiiinciit.      'I'hc  hnii 


■I'llliaell,   ill   uhicii    coi 


sevci'e  and 
cliiiijrcii 


(Ml 


hill  It  lliav  he  sill 


het\ 


•-lioriiiii 


Tl 


K'lallircissoiiieliiiics  el 


cell  the  |>arux\-.iiis|hei'( 


i«'|'"'-'''>  ilsiiallvaeei 

I 


ii<i   1-  a   not  inli-e- 
I'Valed  diiriiiu'  the  at- 


V  may  lie  n  >ensatioii  nf  siil 


lerale. 


IntI 


le  inter- 


l|;iv  |i.v  several  tmportant  symptoms  on  th..  part  of  the  m „.,. 
I  n-usseaw  h.iind  thatj.ressnre  o,i  th,.  nerve  , VnnU  o, ' 


IK'ss  in  the  liilisele; 


III  allaeiv  of  .-.pasin  in   ll 


••I've  triinlss  oi tl 


I's  and  ner\('.' 


I-  iH'l  over,    the  paroxysms   mav   I 


uiseles  of  the  linili 


le  \ c-se 


iiroiiLiht 


iiiMiiit  has  heen  free  from  th 


H'   ri'prodiieed   at    will 


"  i"iii:  MS  the  alta<'k 


l;^"  I •-  "!•  Ill'ire.      'I'his  isalll'ete.l  I 


•  '111  lor  twenty-hair,  thirl  v-i 


•  ■Veil   tlioiiuli   ihi 
'"I'l.^-fiiiht,  seveiitv- 


'.y-^imply  e,,mpiv>sino.  tl,,.  allheteil 


;;"'";'"  "-•'"••■•■'i';"   yni-irpHn-'ipalnerve-irunks 
v.'.M'k  so  as  t..  impede  I  he  venous  or  arterial  e 

••liiii'ii.'lei'i.slK'cii.sesti-lit  pivs>iirei nd  ll 

•■lamp  of  the  milseles  of  th,.  ||,.,||,|_ 


parts 


ii'i'iiialioii. 


"••  "Vcr  their   hlood- 


(T 


iii.sseaii. )      h 


llervcs. 


!•' wri>i  may  hesiilHeienl  to  pr,„| 


Mr,' 


A 


a  I'emarkaMe  iiien 


veiysli-ht    tai 


ill  ll 


!•■  iiii'^'liaiiieal  exeitahil 


iliii^'^  iiriive  e<aitrai'tion  ;   if  with   tl 


piiii;'  in   the  ('oiii'.se  of  i 


ilvof  the  mot 


niililc  III  tile  eoiil'-e  of  tlie  facia. 
i-  ih-trihiited  will  he  instanlK  || 
!i-  llic  liieial  phenomenon,  or'('| 
tftiitiy,  and  mav  occas 


If  pi'i'eiissioii  I 


nerve  on  the  eh,.,' 


I  nerve  is  siiHicieni  to  |  . 
•'''  lln'  sjiiihtest  tap  I 


or 


laiiim 


!■;,  the  m 


n'o\vn  into  active  eoiitraeii 
\'ostek's  sv 


seles   |.,  will 


on. 


'I'hi>  i~  |. 


.yiiiptom.     [t  i.<ii,,,  eharaeh 


si.l;'ii  1-;  the  n-reat    ii 
iKi'li's  syiiipioni).      Tl 


'>iiiilly  he  iiidiieed  in   liihereiilosi.s.     .\ 


ell  It 
Known 
ri~tii'  of 


(■"iitnictioii  of  the  tilee  inn.- 


•  '■••■ase   in   the  eleetriciil 
•rent  from  a  sinol 


•  'Xeltal)llll\ 


Very  important 


le  eii 


ACIC,  K()(" 


I'l^'S.      "  [listead  of  tl 


f  ffii  ma\    he  >iifi 


I'l  I  he  motor  iierv, 


A(  iC.  KCIC.  AOTe."     (( 
iistly,  tile  meeliaiiieal 


\<><',  we  have  I,  .\( 


ml 


'owei's. ) 


If  normal 

AOC;   .-!,  KCIC,  ,a.'l 


ii'ient  to  cans 
'••lion  I,  KCIC 


A()( 


;il-"  -really  increased  ( floff 
"■  -iipni-oriiital,  tiie  aiirieni 


mid  electrical  exeitahiliiv  of  tl 
iiiannV  symptom),  and  tiie  slight 


le  .seiisia'v  nerve 


ins  ina.i^niis,  or  the  ulnar 


il|li.v  iH'i'vewoiihl  only  p,-,„l,„.,,  ;,' sli-ht   local 
' ' '     l"""'^  1"  which  the  lilament: 


lU'i've.' 


fst  pressure  ,)ii 
which  in  a 


;"'N-r  para'sthe.sia  in  the  part 

ii'liiiil  symptoms  are  prof 


"-■.'•l'»^  iii-ticaria,  nutritive  eliaiiM-e.. 
^kiii,  aiKl  III   rare  instances  h>eal 
•••'ticxes  are  iisnallv  iiorimil, 
'"''■  '•^■•■.  lint  epileptic  att 


use  sweatiii!.:-,  n'demat 


'iisilioni  IS  sntKcient  t( 
are  <listril)iite(l.     Oth 


in  tl 


K'  "ails  and  haii 


"US  sweliiiin-of  tl 


•»i'  .iroiural  atrophv  of  th 


le  skill, 
>i,!.;nientation  of  the 


sometimes  ex; 


.irffateil.      I'svchi 


e   111 


llsi^les.      Th. 


'''"''  •"■'■  iiitermitteni,  tl 


icks  have  heen  di-eril.c,|.      '1 


'IIS.  lift,.]!  in  th 
-"iiii'tiiiies  diiriii 
"■"'.V  •■xist  wiihoul  tl 


ify  are  .sometimes  remittent,  or  tl 


•  •al  distnrhan 
tl 


ees 


I'lii.uli  tlie.spa,sms  as  a 


f  simc  ea.se.     ft  is  .^tated,  too,  tl 


Tl 


If  re  are  ea.ses 


in  which  I) 


jvoiiicii  111  techi,,  in.,dtl,,  ^vho  1 

niiml; 

tliiit 


i(>  spa.sms      ( Jowers  speaks  of  a  variet 


ify  may  he  eontimi- 
■•^pasins   mav  persist 

par,-estiiesi:e  and'siitiiu..>> 


lat    the 


tlii'i 


11  iiwakeiiiiiir,  wliii 


lave  a  teeliiin-  of  stitli 


.vniet  with  in  adult 


f  are  mstai 


ll  may  la.st  for  a  ) 


and   tiiiLilii 


i;:'  ill  th 


1'^  III  which  this  "si 


fw  miiintfs  or  loiiaer.     He  s; 


•■fp  tetany"  recurs  throuoh  the  .hi 


av." 


M 


1< 


222 


yi:i!\'))i.s  i)isi:.[si:s  .wd  1111:111  THhwr.unxr. 


The  cniirsc  uf  ih<    lisciisc  is  viTv  viirialplc,     'I'lic  |iiili(iif   iimv  Imvc  un,  ,,i 

l\vosli;.'lit   iiltack,-' mill  no  rfciirrcncc.  or  it  iiuiv  la.-'t   fur  many  iiioiilli- | 

then  airain,  as  in  tlic  casi'  aluiVf  nicntioiii'd,  it  uiay  rcciir  tliriHiirli'int  a  |"  ii.„| 
i>t'  vcMiv.  'riicrc  .in  instmircs  in  wliicli  it  has  rcriirrrd  year  liy  vcar  ihiiin- 
the  winlfi'  niiijiilis.  In  a  few  instances  tiie  disease  proves  tiital.  'I'ron-viii" 
nieiilioiis  siicli  a  ease  in  whieh  \vi(h  very  violent  coniraelioiis,  |iMrtienlaiK  of 
the  nmsehs  of  I  lie  face  ami  iieeL,  asphyxia  developed  and  caused  d.inli, 
.More  -erioiis  are  the  ea.-es  whieli  follow  exiirpation  of  the  thyroid  and  ilm,, 

which  devel  )p  in  inection  with  dilatation  of  the  stomach.'    Children  imi 

infrei|nenilv  die  of  the  disease  causinj:  the  exhaustion,  nirelv  of  tiie  teiain 
itself 

'l"he  aiialomicai  condition  is  unknown,  nor  is  its  j  itlKdo^rv  as  vet  ihir 
The  oecnrrence  in  epi.lemic  form  has  lieeii  held  to  .-Ik,,,  the  in'fei  'ive  I'iiii.i, 
terof  the  di.sea.-e.  The  oeeiirrence  alter  lh\  roid  extirpation  and  in  ilil,iii|. 
tion  of  the  stomach  snji'^resl  its  dependence  upon  some  toxic  material.  !■.  ih, 
nature  of  wlii(di,  however,  we  have  no  clew.  IJoiiveret  ami  Devic  in  ci-i. 
of  tetany  in  dilated  stomaeh  have  extracted  from  the  stomach  eonieiu.  :, 
material  which  they  stme  produces  a  tetany-iike  irroiip  of  symptoms  in  imi. 
nials.  Iieeentiy  ( )ddo  and  Sarles  have  reported  a  ease  of  tetanv  in  n  mM 
au-ed  eiLditeen  montlis,  a.ssociated  witli  retention  of  urine  and  anasarca.  I  in  i 
wa.s  however,  no  aiimmiii  in  the  urine,  lint  indieaii  and  an  excessive  <|ii;ni!ii\ 
of  earthy  phosphates. 

Diagnosis.  Typi<'al  forms  of  the  disea.se  are  very  readily  reeonni/.ed.  ||\,. 
teria  may  sinmlale  it  vi>ry  clo.sely,  hut  neither  Trousseau's  iiheiiomeieiii  i|,,r 
the  increased  excitaliility  of  the  nniseles  and  nerves  is  present.  In  i  ;i,  in. 
stances  the  disease  nii.uht  lie  mistaken  for  idiopathic  tetanus  when  the  -|i;i-in- 
are  widespread,  and  in  .such  a  ca.se  the  etiolojrical  factor  would  he  iiki-i  ini- 
jiortant.  Some  writers  include  with  tetany  all  ca.ses  of  carpopedal  -pii-m. 
in  children.  This  has  lieeii  done  liy  (Jriffith  in  his  recent  paper.  It  i-  im,., 
as   he  says,  that   there  arc  numlierlcss  L'-rai  hit  ions  lietwcen  the   condiiii.n  .4 

Well-marked,  widespread,  intermittent  c<inlractions  and  tin ntinuons  .niii- 

termittcut  carpopedal  spa.-ms.  While  reeo^.nii/.in^'' that  there  are  iii-iaiii,- 
iii  rickety  children  in  which  more  extc  've  spasms  oecur  than  tho.-e  of  il,, 
ordinary  carpopedal  form  and  with  th.  n.  .acterof  tetany  (sometimes  wiili 
larynL;isniiis),  yet  I  tiiink  it  is  liettcr  I  i;  .t  the  name  to"  those  cases  wliiili 
with  the  ^pasni  show  marked  iucrea.se  ii  ■  mechanical  and  electrical  ivcii- 
aliility  of  the  muscles  ami  nerves. 

Treatment.  When  the  spasms  are  severe  chlorotlirm  inhalations  niav  li. 
used,  ii.s  recommended  hy  Troiis.seaii.  The  entire  ranj^e  of  anti.spa-iiiiiilics 
may  he  tried,  usually  without  any  henetit.  Such  t<inies  as  strvclmine,  ar.-ciiic, 
and /ine  are  apjiriipriate.  (Jowers  speaks  highly  of  the  valerianate  of  zinc 
with  liromide  of  iiotassiiim,  and  for  the  nocturnal  tetany  a  dose  of  dii;ii!ili- 
at  liedtime.      Ice  to  t  lie  spine  and  electricity  in  its  various  forms  niav  he  iimiI. 

Where  possihle  the  treatment  slxiiild  lie  directed  to  the  undorlviu'j c ii- 

tioiis.  In  the  stomaeh  ca.ses,  as  the  coutraetiires  very  often  folliiwdinrilv 
U|i(in  the  use  of  the  tuhe,  this  should  lie  re.strieted  as  much  a.s  jiossihle.  W'lirii 
the  disease  has  followed  extirpation  of  the  thyroid,  the  extract  of  the  i;l;iii.i 
may  he  j^iven,  or  a  jiortion  of  the  thyroid  may  lie  transplautt'tl. 


DIPHTHERITIC    PARALYSIS. 

Nature  of  the  Poison.  Koiix  and  Yersin  showed  by  tlie  inoculaiinii  uf 
animals  with  the  cultures  and  with  the  toxins  of  tile  diphtheria  haiilli 
that  a  peripheral  paralysis  could  he  produced  similar  to  that  which  mciusiii 


rMi:.\T. 

lit   iiiiiy  liiivc  iiiM  III 
I'  nimiv  iiioiitlis,  ;iii,| 

tlll-llll^rlllltlt   II  |irl'iM<| 

yciir  liy  year  <liiiiii- 
I's  liitiil.  'rr(Mi"iiiii 
lions,  |iai'liriiliii'l\  ,,f 
I  Mini  i':iiisi'(|  ili'Mih. 
lie  lliyniid  iitnl  ih..., 
lacli.  ('hildi'cii  ii<,| 
rarely  itf  tlic  ti  lanv 

lidliiiry  a.<  yet  ,  Irm-, 
llic  iiif'c(  Mvc  cIkiimi  . 
latioii  ami  in  ilil;ii;|. 
ixic  iiiatcrial,  i.  iln 
and  Dcvic  in  (im, 
stoniacli  I'lmiiiii-  a 
)('  syiiiptiiins  ill  aiii- 
i)t'  tetany  in  a  ■  iiJM 
ind  anasarea.  Tin  iv 
n  excessive  (|n;iiiiiiv 

y  reeiiiriiizcd.     Ii\- 

I's  i)iien(iiiu'iiiiii  ||,,|' 

iresent.      In  r;iiv  in- 

HIS  when  the  -|i;i-iii- 

\v(Uild  he   iiin-i   iii|. 

ear|>()pedal    -|i;mii> 

t  iiaper.     Ii  i-  nii,., 

■n  the   cDiidiiinii  (,| 

le  eontiiuKiiis  III'  in- 

tliere  are  instance- 

ir  than  thiw  nf  iln 

ny  (sdnietiiiics  uiih 

ci  tlldse  eases  wliiil 

and  electrical  cxrii- 

iiihalatiiins  m.iy  in 
c  of  antis|)asiiinilic.  | 
stryehniiie,  aisiiiir. 
valerianate  of  /inc 
•  a  AoM'  of  diiiitali- 
(nrins  may  he  iimI 
?.  undoriyiiiu'  inmli- 
iften  t'dlldw  diivciiv 

as  pussihle.  Willi: 
xtracr  of  the  ;;l;ui  i 
lanted. 


tlio  innculaiinii  4 

diphtheria    luii'illi 

hat  which  nrciifsiii 


ill 


I 


rxF/yrnf:'  d/skas/:. 


niii 


M.     Tlio  oltscr 


223 


lie  (•licniic 


ill 


viitioiis  „r  Sidncv  .M;ir 


.let 


l>ri)(Iiicts  of  tlic  (lijijitl 


tin  1)11  ill,,  clianici 


iIImi 


<>  cxtnict  fniiii  ih 


an  ainiiinosc  and  un  ori: 
iiijcricil  siihriitancoiislv 
liiiiiica 


I'  spleen   an 


itnic  acid, 
pyrexia,  1( 


Tl 


'I'la  liacili 
li  liiiiod  lit' 


ii>  lire   must 


''!■  iind   actmn^ 


'iiipnrtant.     Ih 


ic  alliiiiMiisi 


|1(IS(I|1>  d,.i„|  of  (lipliil 


ly  was  shown  to  he  (hie  to  d 


ilfi'  I 
iiiiinial 


it   the  nerves.     Th 


'ss   in  weit-ht^ 
o,!,^enei'atioii  an 


•'  pi'iKhieed  i 


lena 


and 
il  all 


litr:;rr  doses  wei 


I'l'y  siiniiar  results  f 


01  weiirht  w 
"llowed  the  i 


asa  verv  slrikinu.   | 


II  aiiiniais,  when 
paralysis,    which   aiia- 
"Pliy  "f  the  ax  is 


V  necessary.     .Martin's 


",)''''ti"ii   of  the 


cylin- 
caf   v    ill   ihe 


That  the  hacillns  f 
products,   viz. :  all 


orn 


IS  111  the  dipl 


cdiichisioiis  ar 


'iruan;.   acid,  iiut 


Iniiiid  111  the  tissues  of 


)iinioses  and  ai 


iflit'i'ia   nieinhr; 


'<■  as  tollow.- 


I   oro-.,iii(.  ;„,,■, I 


Hf  and    in   cnltiii\ 


That   Ihe   pliysiolcoicj,] 


""'■sons  dead  from  diphij 


|in"hicts,  vi;;. :  fev 


actions  of  s 


(l,.n-,.|ier 


,-|iiiii(liiii;-  siiDstaiices  ohtaiued 


cr,  emaciation,  and   proj,- 


icria. 


mule  or  i 


Kiiiitical   with   tlio>e 


itioii  of  the  peripheral 


ressive  mu 


peated   doses  of  |1 


nerves,  are  ti 


■ciilar 


itself 


ii'oin   the  tis 


le  same  as  tli( 


■lies,  and 


tl 


lese 
due   to 
U'  corre- 


llie  pheiionieiia  of  tl 


riiat  the  hacillns  is  therefore  tl 


4.  "That   it  lil 


•erates   m   the  iiieml 


le  ])riiiiarv  infect 


i:ist>  the  [iroteids  of  the  hodv,  f 


That  these  are  tl 


.«is,  ciiiaciatioii,  and  deal  I 
'!.  ■•That  the  relati\;'l 
)lit 


le  iininediat 


inlirane  a    ti 
i'lmiiii;'  allium 


ivc  aucnt  il 


rii 


le 


1  di|)htlieria. 


'"'I'f    "hich  when  al.M.riied' 


e  agents  m  the 


I'ses  and  an 


oruaiiic  acid. 


!>i'|iductioiiof  fever,  paraly- 


ly  enorinoiis  (luantitv  of  tl 


s|ii('iii  Mil  (liplitlieria  as  in  anthrax)  is  ex 
I'li'icids  normally  present— staanatii 
than  ill  the  uH'iieral  circiilationr 


])Iical)le  l)v  the  1 


lese  product  fou 


lid  in  till 


'-'  -^o  to  say— in  the  hhiod  of 


iri;<'r  proportion  of 


the 


Anatomical  Changes.     Tl 


■ph'eii 


'i'l 


icre  niav  I 


le  central   nervous  s 


liifi.  and  the  smal 
•il 


"■  'I  sli-ht    iiililtration   of  tl 


ystem   is  not, 


as  a 


ler  vesst 


Is  I 


'l'l"li''ii:i.iiacilli   are  not  found   in    tl 


lave  heen  tluind  hloeked  will 


le  iiieiiiiiH-es,   hemorri 


e,  111- 
lauic 


lavcdescrihed  chaiin-es  in  the  mot 


le  nervous  svsti 


1  micrococci.     'I'j 


linal  cord,  hut  they  are  not 
i(^  nerves  show  iinporfaiil 


T 


eonstant. 


i)f  nerve  cells  of  {] 


M 


le 


le  anterior  hor 


inv  ohserver- 


lis  of  ih 


\'iil| 


in  in  those  of  tl 


<liaim-es,  which  were  first  d 


^'  palate,  hy  lUiU\   in   tl 


'"  '"''peripheral  nerves  hy  Dejeriue.    '  Tl 


le  spinal  ii 


eserihed  hv  ( 'h 


'iiiil"ii<  or  interstitial   neurit 


le   toxilies  produce  eiti 


ircot 
erve  roots,  and 


usuallv  l.,.eii  111  some  proportion  to  the  d 


"iiietimes  hoth.     The  al 


pareiichv- 


leratioiis  fliund  h 


liral  el 


anii'es  present   iiothii 


""11  "I   peripheral   neuritis 
Hiiilihaiis  has  called 


^■irree  of  the  paralysis.     The  hisu'do- 
P"iiliiirJieinn- those  descrihed  under  tl 


le  sec- 


ilvni.       ( 


raiiiil; 


itlention   to  the  fact    that   t 


IIIIISC 


11'  and   faiiv  deu-ei 


leration    is,    of  eou 


le    muscles 


are  ah 


O    111- 


'■■■  of' the  palates  hut  in"  the  paralyze.l,niis,-I 


I'se,    eoniiiion    in    the 


thi'i'c  iiia\-  he  a 


verv  iiiteii; 


e  interstitial 


Symptoms.     Paralysis  fi.llowsdip'hti 


es  111  other  parts  of  the  I 
iiKl  parenchymatous  mvosiiis. 


101  iv 


'■isi's.  raii-iiio'  fnmi   ten  to  tweiit 


plitlieria   in   a   verv  varial'.l 


11-^  llic  seventi 


iMIValc 


'•r  eiahth  dav,  it 


I'cllce  from  the  <lis 


y  per  cent.      Whjl 
is  more  strictlv 


e  niimliei 


e  It   may  develop  as  earlv 
I  seipiel,  not  maniU'st  niitii 


I'liy  part,  and  n 


ease  IS  well  estahlislu;!.     It'may  foli:;;;' d 


iti'i'  Verv  much 


lay  occur  after  verv  sli-ht  f 


Tl 


l< set  IS  llsilallvsl 


less  apt  to  suffer  than  adult 


onus  of  the  (li- 


iplitheria 


ease.     Child 


reii 


"W,  and  not    maiiifisted  I 


ly  any  recurrence  or 


"""""  'lie  local  throat   svinniom.    m.r  i.l,,..   ' '    ",' '""■"«•'' "'•  a--ra- 

""I'-'iiii:-  point,  to  which  ;,t! ',  ti  ,'.  'l/'  "'^•'•'■- ."■■;/'  nile.  anv  f;.ver.  An 
r^"'"  imd  l{.  L.  Ma  I)on\''H,  T'''*7:';'^ '•=''''■•'''>• '''■'•'''''''•'I'. 
'''■-'"'•'■  *'•">"   <liplitl.eri  .       ,   mav   U    .;;"!:  .''i:  'V'"' ■'"''S ''"-'^  '-'- 


224 


XICJIVOUS  I)[S/'JASi:s  AXD  THEIR  TREATMKyT. 


<: 


I 


It  is  innxirtMiit  to  Ix'iir  in  miml  lliat  it  (icciirs  in  iiliciiit  twn-tliinis  (if  nil  r,,.,-. 
and   tiiat    it    is  luit   ncccssaiily  assdciatcd  witli  or  followed  liy  iiaralysi>. 

Local  and  livncral  forms  of  (li|)litlu'ritic  paralysis  arc  recognized. 

r^ocAl.  I*Al!Al,Vsis.  {!()  J'ii/(iti\  jii'iiirjiii.r,  niid  /uri/ii.r.  By  far  the  iim.,| 
(■onirnon  form  is  the  aradnal  loss  of  power  in  the  nniscles  of  the  palate,  inili- 
eate(l  hy  a  nasal  tone  of  the  voice  and  difHciilly  in  swallowinLi'.  The  ciiiiii^ 
in  the  voice  is  due  to  the  fact  that  in  the  pronnnciation  of  certain  woi'd-  ili,- 
cavity  of  the  nose  is  not  shnt  oif.  In  conseipienc"  also  of  this  iindiiliu  !|m 
patient  cannot  distend  the  cheeks  or  Mow  ont  a  candle  nnless  the  iim.,  j, 
held.  The  difficulty  in  swallowinu',  manifest  hy  rcLiiiru'ltation  of  liniiiii- 
throULi'h  the  nost',  i-- variable,  heintr  nnu'h  more  marked  in  some  in^i.inr,  , 
than  in  others.  The  i)alate  is  seen  to  he  relaxed,  haniis  more  verlicalh.  ;iii 
cannot  he  raised.  When  touched  the  sensation  is  also  nuich  impaiiMl, 
Atrophy  of  the  muscles  follows  the   paralysis,  and   the  reacti(ai  of  dcLivii,  i;|. 

tion  has  been  obtained,  thoniih  with  difficulty.     This,  the  slin-htest   ;md  i i 

transient  form  of  dipiitheritic  paralysis,  may  disap])ear  spontaiu'onsly  widiin 
two  or  three  weeks.     Occasionally  uiulateral  facial  paralysis  occurs  wiili  ii, 

When  tlu'  muscles  of  the  pharynx  are  involved,  which  is  fbi'iunalcK  n.i! 
:.o  conimou,  the  act  of  swallowing'  is  accomplished  with  diiHculty,  or  in  i\- 
treme  cases  may  be  impossible,  so  that  the  patient  has  to  be  fc(|  with  a  iiiln'. 

Involvement  of  tlu'  lai'yngeal  nerves:  "  I'ai'alysis  of  the  upper  p;ir! 
fsujierior  larynueal  nerve)  is  more  frecpu'nt  than  that  of  the  voial  im|,|- 
f inferior  laryuLi'cal  nerve).  In  tbt'  formei'  case  the  eiiiu'lottis  stand-  iik; 
against  the  base  of  tiic  tonu'U(!,  and  does  not  descend  over  the  o|)eniiii:  dnriii. 
the  act  of  dcLihitition,  in  conse(pience  of  the  wcaknes.'.  of  the  de|Mv--iir., 
The  upper  piii't  of  the  larynx  is  insensitive,  althou;.;h  when  a  fiu'ciiiii  IimiK- 
reaches  the  vocal  cords  pain  is  felt,  llenco,  fooil  is  apt  to  jret  into  the  l;it\ii\ 
ami  to  cause  couuhiuL;'.  The  voici^  is  hoarse,  pi'ohably  in  consei|Ui  nci' .ii 
paralysis  of  the  crico-thyroid  nuiscle,  but  the  vocal  cords  move  as  usual,  li; 
otlitir  cases  there  is  paraly.-is  in  the  rcLnon  of  the  inferior  laryngeal  iinvr. 
anil  phonation  may  be  impossible.  The  laryniiiisco])!'  then  shows  iuminlijlitv 
of  the  cords  and  sometimes  a  pi'cpoudcrant  weakness  of  abd\ictiou,  -^  tlmi 
the  corils  are  not  separated  dcriiii:-  inspiraticai.  In  one  fat.al  case,  al  ilnin,! 
of  the  first  week,  swallowing- was  impossible,  and  there  was  complete  niii|,ii;iii, I 
sensory  paralysis  of  the  larynx.  '  ((iowcrs. ) 

{/>.)  SjiicIk/  .ini''i-'<.  I'araly- is  of  the  eye  muscles,  intrinsic  and  e\ii-iii-ii'. 
is  not  uncomiiiiiu.  Lossof  the  jiower  of  accouunodatiou,  due  to  atlictinii  hi' 
the  ciliary  nai-cle,  and  loss  of  the  liulit  reflex  may  be  present.  I'ln-i-  ami 
external  and  internal  strabisnuis  ai'c  occasionally  seen,  and  in  rare  iii-tnnci- 
complete  o|)hthalinople;.Na.     There  may  be  ('(infraction  of  flu-  fields  olxiMnii 

It  is  UHU'li  rarer  to  have  the  other  special  senses  involved,  hut  cax-  an m: 
record  of  loss  of  the  sense  of  taste,  of  smell,  and  of  hearint:'. 

(r)  CiiriliiK'  iirrris,  N'arious  forms  of  arrhythmia  are  i  it  \inconniinii.  I'lii 
heart's  action  may  be  slowed  to  twenty  or  thirty  beats  per  minute.  In  nilm 
cases  there  may  be  tachycardia,  or  the  two  conditions  may  alteruaic  in  tin 
same  patient.  In  othei'  cases  the  j)ulse  is  irreaidar  in  volume  and  in  iliyllmi, 
hiatal  svncope  mav  occur,  either  at  the  lieiLiht  of  the  disease  or  dininu  rnii- 
valescence.  <  )ccurrin;i'  durini:-  the  fever  the  child  may,  after  an  exai:;;i'ialii'ii 
of  the  symptoms,  present  niuisual  palloi';  the  ))ulse  may  cithei'  be  \M;ik  ainl 
rapid  or  may  be  not  more  than  forty  or  titty  ;  the  extremities  arc  ■  njil.  iln 
temperatui'c  sinks,  and  dcjlth  takes  place  within  a  lew  hours  wiili  nil  tin' 
features  of  collajise.  .More  ofti'U  the  fatal  event  (*iccurs(lurin!.;('on\nli'Mi'iiiv, 
even  as  late  as  the  sixth  or  seventh  week  alter  apparent  reco\(  ly.  lin' 
attack  mav  occur  abi'ujitlv  while  the  child  is  in  bed,  or  may  follow  a  sinliicii 
exirtion  ;  more  commonly  lln'ie  iiavi'  been  .symptoms  [lointinu' to  ilisturhul 


Mi:XT. 


i-tliir(ls  (if  iill  cn-t., 
I  liv  pariily.-ir, 
('(•(ii;iii/i'(l. 

By  fill'  tlif  iii(,-( 

III'  lIlC  pilllltC.  illili- 
Willii'.        'rilC  cll;!!!",' 

if  (•(■rtiiiii  WdrcU  ih,. 
if  tliis  iiiiiliilii\  ilir 
(!  unless  tlic  iin-i  i- 
rji'itiition  (if  lii|;iiii. 
1  ill  sdiiic  in-iaiicc- 
iKirc  vci'ticalK'.  ani] 
<ii  iiiucli  iiii{iaii'M|. 
iii'tiiiii  (if  i1('l;'iii(  ra- 
'  sli^'liti'st  :iihl  iiin-i 
)()lltilll('(Uisly  w  iiliiii 
:sis  (icciirs  w  iili  ii. 
li  is  i'drtuiiaicU  i;ui 

(riiliciilty,  111'  ill  i\- 

1)1'  fed  with  a  liilic. 
if    the    iijiiicr   |iMii 

(if  tlic  vocal  ciirii- 
uiiiltis   sraml-  ivni 

till'  (ijn'iiiiiL;  liiiriii:' 
;  (if  tlic  (1c|iivhm,|,. 
Iii'ii  ii  fiircii^ii  I.M.Iv 

<ret  into  the  laiMi\ 

V  ill    C01ISCi|llt  Hit  n\ 

move  as  usual.  In 
ir  iaryiiiical  ihtvc, 
■11  shows  iniiiinliiliiv 
f  ahiluctioii,  •'!  ili;it 
itn!  ca>c,  al  ilir  iihi 
coni|)lcti'  iiiiilniaiid 


I  Ii 


■msic  ami  i\niii-ic. 
,  due  to  atliTiidii  "i' 
■(■sent.  I*lu-i-  aiiil 
111(1  in  rare  in-iaiirc- 
the  lieids  (irvi-inii. 
ed,  but  cax-  inviiii 
111:'. 

it   llllCOIIIIIln:i,      Till' 

r  iiiiniite.  in  <iili'! 
nay  alteniair  ii:  ih. 
inie  and  in  rhyilnn 
-ease  or  diliillL;  mil- 
i'ter  an  0NaL:;:i'i'iiti"ii 
either  lie  "rak  ;lii'i 
iiities  are  niM.il,. 
hours  with  all  tin 
ii'iiiu'convalcsci'iiiv. 

cut  n \ciT.    Til'- 

nay  follow  a  -inMiii 
ointiim-  to  ili>iiii'liei 


I 


i* 


L\rE(T[VK  DISEASES 


ciiiiliiic  rliytlini,  or  tlioiv  liavc  iKrii  faint 


iirrccdci 


1   tl 


ic  attaci 


AWm  increase  in  tlic 


Tl 


iii^'  s])ells.     I 


n  sonic 


H'lv  arc  not  often   i.iiysical 


area  of  dninoss  and  t 


I'sc  senons  syinptonis  arc  ascriiu'd  t 


H'  jircscncc  of 


225 


cases  voinitnitr 


nan 


-'fills  other  t 


ii  ii 


liloj)  rliytliii 


tniisK'  heart  nerve? 


I 


liy  ^fosler  and  liv  f^cvd 


ossihlv  111  SOI 


";!  ■"■Mntis  of  tlie  va-i  or  of  the  i 


Me  ol   the  ,.., 


<ii:\i;uAi,  I' 


UtAl.Vsl- 


t'li,  is  an  infections  i 


tl 


iiii  iiicaiis  unooniinon. 


wi 


th  the   l( 


It 


Tl 
nsuailv  I 


nyocarditi 


lie  lesi(„i,  as  ],oi,|(j,,|  ,,|,j 


ic  multiple  forni  .  f 


oAs  (It  a  coniniodat 


H'j-ins  with  an   afl. 


'I'lillK'ritic  jiaralvsis  is  l.v 


It   is, 


i.<  a  rnle,  hilateral 


'""    i"   tlu'  eye,  and  an  ahs: 


cction  of  the  j,,,hit 


c,  or 


ilaiiH  that  tliev  are  I 
ik 


iiivol 


nee  of  tendon  re 


tlic  weakness  i)roo-resses,  and  the  para) 


leavy  and  stiff;  and  that  he  t 


viii-  ill.'  leas  first,  and  tl 


ires  easil 


l)iitient 


y.     (ii-adnallv 


iii\olve  ehieflv  tl 
.1 


le  extensor  or,,„p.s  „f  luusclcs."     Tl 


'U-ia  may  hcconie  complete,  or  it 


iiKl  involve  the  amis  and  face  and 


render  tli 


paralv- 


may 
mav  extend 


le  muscles  nsnally  waste,  and  there  is  a  d 


e  patient  complctclv  helpl 


(if  the  fil 

often 

ill  the  form  of  luimhi 


radio  irrital.ility.     The  sphincters  mav  1 
[tared,  even  when  the  paralvsis 


pi  CSS. 


may  Ik; 

ill  which  soni 


tin 

MCCl 


IS  exleiisiv( 


iininiition  or  even  complete  loss 
'V  lie  involved,  thoii'di  tl 


IlIlL 


Distnrl 


nd  amesthesiu  mav  devel 


present  as  a  verv  special  feature;  thus  Hall 


nrliance  of  sensat 
'P.     Amesthesia 


lev  are 


ion 


liirlal 


e  paresis  of  all  four  ext 


parts,  ill  the  arms  not 


the  I 


iiiddle  of  the  thi<.dis.     Tl 


extendiim'  a 


romities  occurred  with 


i.U'cr'   re))orts  a 


)ove  tl 


n  instance 


intercostal  muscles  and  the  diaol 


nnisclesof  respi 


le  el 


laiuestliesia  of  tl 


le 


dll 
iti 


le  mnscles  o 


f  tl 


It'  neck  and  hack  i 


if;ni  muscles  ar 


''ow,  and  in  the  leux  to 
••ation  are  usually  spared!  Init 


iicitlicr  turn  over  nor  hold  np  his  head 
'''lie  outlook,  of  ( 


lay  he  so  weak  that  tl 


■e  oeeasionally  involved 


e  jiatient  can 


I  lie  outlook,  of  course    in  these  v<.vi-  .,>,.  . 

™','::,,k";»,-!,,:™'"'*'  '">""'■-■''•■  i'"-'--.-:-  ,.,,,1;:::;,, !,;'  ,',',k  c.,^^ 

Tl,,.    .I,,"....:-      ..         J-     .1 


cdiu't  onlv  (i  (lied.  .•  -  "■ '>^  ^  we  vtiussi- 

.™';.;I;;;;:';';;;;;'  Tzzsc  :z?zzt  "'j^'";''  •■ -"■™'  ■ "- 

-' ' •■-■•■■  ■  .li.i "."r;;;;;,,  I ,,.r ;: ,,:i ;!:::"■;;'  -""'™>i" «i 'i.« 


I"  <iM  irjuic  \  ear.      i    reniem  her  t  i,.    ,.....,     v  i-      ,     


"»|"iarviixanu  iarviix  are  serioiisK-  i„v,,lv,.,l  ',  ■■.■■■:,'"—""'•>  "'  wnnii 
'i'"'  "f  tlu' heart.  The  most  .lam  ei  us  •  H  '  '  ','•  V"'  '""^^■^  "'f''  •''<"'^- 
I1...I  paUy  supervenes  shortly  ancM^'  1      t;:  lli::  lH'''  ''  -'-'  -'  -«'- 

Diagnosis.      I  he  diatmosis  is  n  ■•  -Iv  doni.tfnl   .1       \'i     1  ■ 
"''''ipl"l'"na   is  clear!     In  nia  iv  i  wt  '     . ''"' 'V/^'"'^^^^ 

"•-I'l"  l.as  iieen  nia.le  maniflJ     ^.      'Z^,      ",  ";'"7  "'  =1  ^'I'-ai  or  nose 

ai'teis  of  that  which  so  oft,,,  t\ wl  li,  I    I    ,;       'VJ'""'-''^''^  '"'^'"'t^  tin'  ehiir- 

l<-"H.;ierks  and  the  slid.t  i  n  -  ^  i  '  ^  ^,  /'"••*"'>:  ^""•I"  the  nhsenee  of 
^itaxia.  uor  is  the  ^ait,'  when   tl  e     "l     s  '      ^  f  '  f   ?'"^""i^  "^  I'^'moUn- 

"■'■'■; nplicatin^  the  -lipl.the  £  pj      l^si?     l'''  '"'    T"'"'  'V^'''"''  ''>-^- 

intal  .,r  lieiniplc.W,.  paiahsis,  ha>  .•anscl  aiuesthesia,  either 

-'::rS!„c;';;';.et:r':md^r''''''' ■'■''■  r"'^-'  ^'--  '^  -^-ik-  a 

i''"i-'-^  ^t,...n,th  and   ';;:,/':;: '^;;''' '•;•'■-;--/'- to suppo,., \ut 

'"">'l-'>  I'.v.'lectncitvand   n  a  s.   v      Tw  '"r''''"'  f''<'  ""fiti.m  of  the 

7'liHMryformsof  peripheanm,  ?is     '    t  ,^;«''"'  I'-^'^'-'ient   is  that  of  the 

•  -N'eurologischfsCcntralblati,  Bd.  ix. 
1.5 


I  •■* 


I  f 


1^^ 


II 


I 


iLi 


^^ 


13 


226 


NERVOUS  DISEASES  ASl)  THEIR  TREATMENT. 


tliaii  li(|uiils.  NVIicn  tin-  pharynx  is  seriously  uivol;!  '  ;liO  paii-nt  nn^i  he 
fi'd  per  ri'ctuiii  or  with  i;  soft  stoiiiacii-tiihi',  thi'  -roatest  liiiv  hciiiy;  oMTciMil 
tliat  particles  of  food  do  not  got  into  the  larynx. 

It  is  too rfoon  to  say  how  far  the  new  antitoxin  iri-atiiient  (the  residr-  nf 
whieh  soom  so  favorahle)  'a'U  diinii^irii  ;'ie  liaiiility  to  these  most  seiiuiis 
se(|nehe  of  the  disease. 

Disorders  other  than  neuriiis  may  follow  diphtheria  ;  thus  nuiltiple  sri,  n,. 


SIS 


may  develoj)  in  children,  as  noted  part''   darl;.   hy  Slavic. 


Ilcmiplegi.'i  following  diphtheria  is  not  usiudly  .hu>  t)  neuritis,  Iviit  lo  nciit' 
•encephalitis  or  to  cerebral  end)olisni  from  heart-dise:;.-''.  Of  Kidca-c;  ol' iii- 
fantii"  '^  niiplegia  in  Wollenhcrg's  statistics,  threi'  followed  diphtiieria.  Ndi 
one  ..^  iiiy  series  of  120  casesfolliiwed  this  disease.  Seifert'  lias  reported  iwd 
interestiii'X  ea-'S  Iioili  in  hildrcn  ahont  the  age  of  ten,  who  had  hail  ilu- 
ordinary  palsy  ni'  the  ihrr/ai  following  diphtheria.  In  inw.  hemi[)legia  ilcvc]. 
oped  sud>'.  id  ;• ;  in  the  other  more  gradually.  lie  has  collected  only  six  <;is(s 
from  the.  litcuture  of  complete  hemiplegia  after  tlijihtheria,  two  of  wliiih 
wore  fat.il,  botli  from  lieinorrhage.  As  in  other  inshmces,  the  conditinn  i> 
jirol)a^ily  dm  to  an  acute  encephalitis,  setting  in  witi  convulsions  and  Icm  r, 
(Jaspar  Sjinrples  ha.s  re|)ort(>d  the  ca.<e' of  a  hoy,  a;.i  I  thirteen  years,  wlm 
during  an  attack  of  diphtheria  wii.s  seized  with  right  Ik  i<ii[)legia  and  a|iliii>iii. 

1  Neurologisclies  Ccntralblalt,  No.  12. 

2  Medical  News,  August  4,  l.S'Jl. 


Studies  in  Typhoid  Fever.— 

Five  Years'  Experience  with  the  Cold  Bath 
Treatment. 


BY 


WILLIAM  OSLER,  M.  D. 


I 


\ 


I 


JOHN  MUBI'IIY  A  CO.,  I'BINTKKS, 
BALTIMOKK. 


Ife 


irr.-FIVE  YEARS'  EXPERIENX'E  WITH  THE  roi  n 
BATfl  TREATMENT  OF  TYPHOID  FEVER 

By  WILLIAM       jLER    M.  D. 

During  the  first  year  of  tlu-  Flospital  sorvioc,  tvphoul  fever  was 
n-<..«l  .symp(,.mat,..ally.  Tl.o  nun.ber  of  severe  .a.L  admitte'l  was 
unusually  large,  and  there  were  eight  deaths  anu.n,  (hirtv-throo 
patientH— a  percentage  <.f  24.2.     For  tlu.  iv.ct  fl,.„  •->  mru, 

-,.l,   180%  '     ,        ,.     ,     ,  '^"' ^'"^1'''^*  nve  years,  ending  Mav 

loll.   189.    .ystemafc  hydrotherapy  has  been  u,se.l_the  method  of 
Bnu,d   w,t     eerta.n  m.nor  n.odiHeations.     J,,  the  first  Ji.,or,  (Vol 
rV)  the  plan  was  g.ven ;  but  I  n.ay  repeat  here  that  ea  h  patent' 
.ce,ve,s  a  tub-bath  of  twenty  nnnutes  at  70°  every  third  hour   wl 
th.     .0 tal  ten,>eratu.e  is  at  or  above  102.oO.     FHetions  are  a'p  it 
..c  bath,  and  a  warm  drink  or  a  stiu.ulant  is  given  after  vLd 

1  the  p.n  s  eeble  wh.skey  ,s  given,  and  strychnia.  The  diet  is 
-  K.r  -I'olly  .n,  k  or  in  part  b-oths,  and  egg  albumen.  It  mt  be 
.ot«l  tha  all  the  cases  come  under  my  i.nnu.diate  care  or  Tn  m y 
absence,  that  of  Dr.  Thayer,  the  Associate  in  Me.liein.  ^ 

In  estunating  the  value  of  any  plan  of  treatment,  it  is  imnort.nt 
that  all  cu-ct.mstan<...s  should  be  taken  into  account.     I„  the  nre 
™  report  I  dealt  with  the  statistics  as  so  many  patients  admu  " 
om  ,so  many  d.ed ;  and  this,  I  think,  should   be  done  in  ali 
r    t.tut,ons-g.vo  the  total  number  of  cases  of  each  disease  treated 
aconcus>on,  and  the  number  of  deaths,  irrespective  altogether  o 
He  length  o    stay  ,n  the  hospital,  or  the  .onditiou  ou  ad.  ission 
0  n..,-al  hosp,t.ds  are  everywhere  liable  to  be  repositories  of  the  n  o   : 
vere  or  troublesome  eases,  and  in  typhoid  feier  more  partieu     ly 
f    n  racted  cases  .n  which  serious  symptoms  ha^.  dellop^l  1  ^ 
ma    h  r       ""''  rate  of  .mortality  in  any  given  acute  disease 

may  be  an  md.cat.on  of  a  s,>ecial  usefulness  of  the  institution      A 
eady  g.ven,  the  general  statistics  of  the  Hospital  in  typho  d  fevt 


I' 


321 


I 


;122  Willium  fMir. 

Cases  iidiiiilti'd  "luring  the  six  yours  eiulinj{  May 
lotli,  1895, 

\miil)('r  of  (It'iitlis,      -         -         -         -         - 

IVrcontiitrc  of  niDrtallty,       -         -         -         - 

Cases  luliiiittcd  lu'l'on- tlic  iiitrodiii'tiou  of  iiydro- 

tiicrapv,  _.-.-- 

NiimlxT  of  (Icatlis, 

I'crcerJn  '('  of  mortality,       .         -         -         - 

Cases  admitted  since  tlic  iiitrodiietion  of  liydro- 

tlierapy, 

Number  of  deatiis, 

Pereentaffe  of  iiinrtality,  .  -  -  - 
Xumlier  of  cases  hallied,  .  .  .  - 

Nunii)or  of  deaths  in  tlie  bathed  cases, 

l'ercentay;e  of  mortality  in  the  bathed  eases,    - 


38U 
34 

M.7 

;53 

s 

24.2 

3oG 

2(i 

7.3 

2it!i 

20 
G.6 


The  percentaj^e  7.3  represents  the  total  mortality  durino-  the  |ki-i 
five  years;  but  as  it  does  not  represent  the  mortality  of  the  i;i-'s 
treated  by  hydrotliera|)y,  the  figures  must  undergo  a  further  analysi-. 
Many  circumstances  interfere  with  the  systematic  earryinj;  out  nl'  ili, 
plan,  among  which  the  following  are  the  most  important. 

In  the  first  phur,  a  number  of  cases  are  admitted  in  the  sccdiHJ 
week,  and  even  in  the  third  week,  with  u  falling  thermometer,  ami 
the  fever  constantly  below  102.0°.  Cases,  too,  are  admitted  early, 
which  have  low  temi>eratures  and  mild  symptoms  throughout,  liraiul 
and  others  urge  that  tlie>e  should  also  be  bathed;  but  in  a  large  pro- 
portion of  all  such  cases,  this  appears  superfluous.  There  are  exci  ji- 
tions,  however, — cases  in  whicii  the  fever  is  low  on  admi-sion.  and 
even  remains  low  for  a  week  or  ten  days,  to  be  followed  by  active 
and  threatening  symptoms.  Nos.  XXII  and  A'A'/A'of  the  fatal  cases 
were  of  tiiis  kind,  and  in  both  one  could  not  but  regret  that  the  l)atli> 
had  not  been  used  from  the  outset.  In  the  very  mild  cases,  mi  ii 
more  frequently  in  private  than  in  hospital  practice,  the  baths  are 
unnecessary.  Last  year  we  admitted  an  unusually  large  number  ot 
such  mild  eases. 

In  the  se(!ond  place  patients  are  adnr^ted  late  in  the  disease,  ami 
are  too  ill  to  l)athc.  A  patient  broughi  m  at  the  end  of  tiic  third 
week,  with  high  fever,  rapid,  feeble  pulse,  meteorism,  and  diarrineii, 


lay 

- 

38i» 

. 

:U 

- 

H.7 

ro- 

. 

;53 

- 

8 

- 

24.2 

ro- 

m 

:}5»j 

- 

2(1 

• 

7.:} 

- 

295) 

- 

2t» 

. 

(5. (5 

diiriliif  tile  |i;iM 
lity  of  the  i;i-<s 

fiirtlior  aiialysi-, 
rrvinj;  out  nl'  tin 
rtaiit. 

ed  in  the  scidiiil 
licrnioniotor,  mikI 
■  admitted  caily, 
•uiiji:lu)iit.  iiraiiii 
lit  in  a  larije  jiin- 
Tliero  aro  cxn  p- 
II  admission,  ami 
dlowc'd  l)y  activi' 
'of  the  tiital  casc" 
ret  tlmt  tlie  batli- 

mild  cases,  -(m 
>ee,  the  batiis  mv 

hirgc  uuniiiri'  ot 

II  the  disease,  luul 
end  of  tile  tliiiil 


,     Fhu    Ymrn'  Krperkncr  iritl,  (he  <  hf,l  Hull,  'JW<>f,n,nf.       ;;2:'. 

^ta..d.s  I  helieve  a  nn.eh  he.ler  .hunee,  with  earefnl  sp.uvinu.  ,o 
'"'•"■;"  »'"•  *^'v<;>-,  than  he  .ioes  with  fihl,iM,r  everv  fourth  ,„■  mU  hour 
an.i  (he  dmtnrimnee  nnuvidahl..  i„  the  hfting'out  of  h.d  The,., 
were  hve  patients  u.hnitted  in  too  feel.h.  a  .ondition  to  hu.he",  no,  one 
i<\  wliom  liied. 

Tl,irdly,  there  is  a  ;:ron|,  of  .,,ses  whi,.h  on  adn.ission  present  serious 
'ympI.mt.onH-huMuorrhag,,  signs  of  p,  rfora.ion,  very  intense  hron- 
.  IntiH,  pnenmonni,  plenri,sy  or  intenso  meteorism  with  severe  .liarrh... , 
On  aeeom.t  of  ha.uorrhage  the  baths  were  postpone,!  on  -everal  o..,..', - 
sK.ns  There  was  no  insta.we  in  whieh  .,n  ..chnission  ,he  puin.unarv 
symptoms  seemed  to  eontraindieate  tlie  treatment 

Fonrlhly,  there  a r."  cu-es  whi.^h  wer.^  not  bathed'  at  tirst  b,ranse  the 
<l.agnos,s  seen.e,!  doubtful.     Two  of  tin.  li.tal  eases,  to  whieh  reference 

will  be  nmde  shortly,  were  not  reeogniz,.!  ejiuieallv  as  tvph li.v.r 

Laehautiunn  we  haveaeertain  number  of , uses  of  n.alaWa  win,.).  „r.." 
sent  features  elo>ely  resend,liug  typiu.id  fever-s„  nn.eh  so  that  baths 
'u-e  been  g.yen.  These  are  instances  of  the  so-eal!e,l  astivo-autnunud 
tevor,  m  which  the  organisms  may  at  lirst  be  ditfieuit  to  lin<l  h. 
other  mstanees  with  a  strong  suspicion  of  n.alaria  for  a  .lav  o,"  two 
the  syn.pton.s  of  typhoi.l  fover  have  developed  subsequently  b„t  the 
twnperature  nuvunvhile  h.as  fidhu.  below  the  bathing  point.  In  several 
'•ases  the  e,.n(htion  at  lirst  resembled  tulxMvulosis. 

And  lastly,  the  baths  have  been  fre.p.cntly  ..hanged  to  ..uhl  s„,„„n.s 
ON  a.;e.,n„t  of  Inemorrlmge,  profound  wakness,  t.n.lerness  and  ,well- 
ing  ol  abdomen,  signs  of  p,.rforation,  and  in  a  few  eases  bec-ause  of 
I'oaet.v..  protestati.m  of  the  patient.    The  sponging,  when  th.n-oughly 
•lone,  .s  almost  as  h.rmidable  a  proce.i„re  as  the  ,.ol.l  bath  :  iiut.! 
ue  have  had  patients  ask  to  have  the  bath<  resinned 

The  tollowing  are  among  the  most  important  reasons  which  eaused 
.•ansient  snspensioi.of  the  metluv] :  I[.>„,orrhage,  1;}  ..a.ses;  perfora- 
ta"., in  wlu..h  condition  even  th.  sponging  is  ra.elv  allowable,  but  in 
winch  the  extremities  may  be  bathed  without  disturbing  the  patient  • 
on  ..count  of  great  weakness  and  prostration,  11  eases;  ,.,.  account  of' 
'f  Y"  mental  symptoms,  f.,r  one  day  in  one  case,  for  two  d.us  in 
ai'otl.er;  for  extreme  tenderness  of  th,,.  ab.lomen,  for  one  .lav"  one 
case;  for  severe  bronchitis,  fbr  intense  laryngitis,  after  operatio'n  . 
al..scess  of  par.>t,d,  fbr  severe  phlebitis,  for  plenri.sy,  eae     one  -as 


324 


Williwa  Osier. 


In  many  of  the  fatal  cases  tlio  baths  were  suspended  for  twenty-four, 
sometimes  forty-eiglit  hours  before  death. 

There  were  several  instances  in  which  the  symptoms  of  relapse  weiv 
so  slight  that  the  treatment  was  not  rigidly  enforced. 

Of  the  356  cases  treated  during  the  five  years,  299  were  bathed,  (jf 
these  20  died,  a  mortality  of  6.6  per  ceiit. 

Of  the  57  cases  which  were  not  bathed  for  various  reasons,  usu- 
ally because  of  the  mildness  of  the  disease,  six  died,  a  percentage  of 
10.3.  This  high  ratio  of  mortality  in  the  unbathed  cases  is,  of  courw, 
due  entirely  to  the  circumstance  that  conditions,  mentioned  below, 
interfered  with  the  use  of  the  baths  in  a  group  of  cases  of  unusu;i! 
severity.  In  the  six  fatal  cases,  the  histories  of  which  are  given  in 
full  in  another  place,  in  two,  Canes  A7  and  XVIII,  the  diagnosis  \va> 
wrong;  in  the  one  an  old  man  of  70,  with  consolidation  of  the  lower 
lobe,  the  disease  was  thought  to  be  lobar  pneumonia;  and  in  the  other, 
the  patient  had  been  in  hospital  tiie  year  before  with  entero-coliti.-, 
and  on  re-admission  with  severe  diarrhcx'a,  typhoid  fever  was  mi 
suspected. 

In  Case  XXVIl  the  disease  was  at  first  thought  to  be  tuberculous 
cerebro-spinal  meningitis — the  temperature  was  low,  the  nervmi- 
symptoms  marked,  and  it  was  not  rntil  parotitis  developed  that  <iur 
suspicions  were  aroused  about  typhoid  fever. 

In  Case  XXVIII,  after  twelve  days  of  moderate  fever,  severe 
symptoms  developed,  with  tympany  and  abdominal  tenderness  mikI 
diarrluea.  It  was  thought  best  to  use  the  cold  sponges ;  death  was 
probably  due  to  perforation. 

In  Case  XXXII  tha  patient  was  admitted,  bleeding  profusely  fnun 
the  bowels,  and 

In  CV;.s'e  .V.YA7// the  fever  was  low,  only  touching  104°  at  en- 
trance, and  subsequently  not  rising  to  bathing  point.  Death  occurred 
from  thrombosis  of  the  middle  cerebral  arteries. 

Two  advantages  are  claimed  for  hydrotherapy  in  typhoid  fever— 
a  mitigation  of  the  general  symptoms  of  the  disease,  and  a  rodi'etion 
in  the  mortality.  Our  experience  during  the  past  five  years  bears 
out  these  claims. 

In  general  hospitals,  to  which  cases  rarely  are  admitted  before  the 
end  of  the  first  week,  the  full  benefits  of  the  cold  bath,  as  described 
by  Brand,  cannot  be  expected ;  nevertheless,  in  any  large  series,  the 


or  twenty-four, 

of  relapse  wei. 

were  bathed,  of 

15  reasons,  usii- 
a  pereentagt!  nl 
ses  is,  of  coursi , 
entionod  below, 
ascs  of  uniisii;il 
ich  are  given  in 

16  diagnosis  was 
on  of  tlio  luwir 
md  in  the  otlier, 
h  entero-coliti~, 

fever  was  not 

»  be  tuberouliins 
A-,  the  nerviiii- 
,'elopcd  that  our 

te  fever,  severe 

tenderness  and 

iges ;  death  was 

;  profnsely  from 

ng  104°  at  en- 
Death  oceiirrcd 

typhoid  fever— 
and  a  redin'tion 
five  years  Ix'ai'.- 

nitted  l)eforc  the 
ath,  as  described 
large  series,  the 


^ 


Five  Years^  Experience  with  the  Cold  Bath  Treatnm^.       325 

severer  nmnifestations  appear  to  he  less  ..omn.on.  As  has  been  nrg.d 
so  often  an(  so  ably  by  many  writers,  the  beneficial  aetion  is  not  so 
raueh  .speeml  and  antipyretic  as  general,  tonic,  and  robnrant.  The 
typhoul  p.ctnrc  ,s  not  so  freqnently  seen,  and  we  n,ay  have  twenty 
or  more  oases  nndcr  treatment  withont  an  instance  uCdrv  ton^ne  or 
of  den-,um  amon^  them.  It  is  a  mistake  to  clai.n,  as  "do  the  too 
ardent  advocates  of  the  plan,  that  severe  nervons  symptoms  are  never 
seen.  I  have  taken  the  pains  to  go  over  carefully  onr  records  on 
tins  po.nt.  There  were  .n  the  first  three  years  thirteen  .uses,  in  the 
past  two  years  nme  cases  with  delirium.  Most  of  these  were  pro- 
tracted cases  which  had  from  7o  to  120  baths 

A  far  .norc  important  clahn  is  that  the  use  of  the  cold  bath  reduces 
the  n.ortah  y  fnnn  the  disease.  The  comparison  of  <leath  rates  as  a 
measure  of  the  efficacy  ot  any  plans  of  treatn.ent  is  n,>torionsIv  ,mcer- 
tan,  unless  all  the  circumstances  are  taken  into  acco.n>f.  In  our  own 
f:.n.rcs  for  the  past  five  years,  fur  example,  illustrate  this-G.2  percent 
in  the  bathed  ease.s^  10  in  the  unbathed  cases-as  the  latter  group  i.' 
nuule  up  enttrely  of  cases  too  n.ild  to  bathe  and  six  patients  i,>  whotn 
either  the  disease  was  not  recognized  or  who  were  too  ill  on  admission 
to  treat. 

Statistics  have  a  value  in  this  connection  only  when  the  figures  on 
which  they  are  based  are  numerous  enough  to  neutralise  in  some 
measure  their  notorious  mobility.     Small  groups  of  cases  are  useless  • 
-t  per  cent,  o    mortality  in  our  first  year  in  thirty-three  eases,  and  a 
.eries  of  nearly   fifty   bathed   cases  without  a  death,   illustrate  the 
abihty  to  error  ,n  discussing  a  few  cases.     Unfortunately,  typhoid 
fever  ,s  a  disease  in  which  the  cases  may  be  re<d<oned  bv  hundreds 
|..Hl  thousaiK  s,  and  the  average  mortality  in  general  and  special  hos- 
p.tals  throughout  Lurope  and  America  is  easilv  gathered.     The  rate 
may  be  paced  between  15  and  20  in  each   lunulred  cases.     In  the 
Motropohtan  Pever  Hospitals,  London,  the  death  rate,  as  given  in  the 
liep'"-'  for  1893,  was  ]  7  per  cent. 
The  eold-bath  treatment,  rigidly  enforced,  appears  to  save  from  six 
eight  in  each  century  of  typhoid  patients  admitted  to  the  care  of 
tlie  Hospital  physician. 

Willie  I  enforce  the  method  for  its  results,  I  am  not  enamoured  of 
tlic  ..actice.  I  have  been  criticized  rather  sharply  for  saying  harsh 
words  about  the  Brand  system.     To-day,  when  \  hear  a  you!,g  g-  , 


1} 


826 


WUliam  Osier. 


say  that  .<he  enjoys  the  baths,  I  accept  the  criticism  and  feel  it  just ; 
hut  tu-morrow,  when  I  hear  a  poor  teUovv  (who  has  been  dumped, 
like  Falstaff,  Miissing  hot'  int  a  cold  tub),  chattering  out  maledic- 
tion upon  nurses  and  doctors,  I  am  inclined  to  resent  it,  and  to  pray  for 
a  method  which  may  be,  while  equally  life-saving,  to  put  it  mildly, 
less  disagreeable. 


Studies  in  Typhoid  Fever:- 

General  Analysis  and  Summary  of  the  Cases. 

Special  Features,  Symptoms,  and  Complications. 

A  Study  of  the  Fatal  Cases. 


BY 


WILLIAM   OSLEK,  M.  D. 


JOHN  MURPHY  4  CO.,  riilNTERS, 
BALTIMORE. 


r.-ANALYSIS  AND  SUMMARY  OF  THE  CASES. 

By  WILLIAM  OSLER,  M.  D. 

In  Volume  IV  of  the  AVnm-/*  /laon         ^    , 
.v,.hoi.l  fever  under  t^^r^      r'i::;:/^'^;^'^';  ^29  cases  of 
ii''^t  '"...•  years  of  the  Hospital  Jk      We  li^  ^T''"T^!  '^'^  '^' 
-.vuk..l  to  conclusion  during  the  sTand  PH  /"'^^  ^^*^  '"''' 

im.  ^  "'^  ^'''  >'""'■«'  e"t''ng  May  15th, 

Siox.— 124  were  males,  36  females 

For  the  xl.v  years.^SU  were  males  and  78  females. 

iiA(i.:._147  were  white,  13  were  colored. 

/'«;■ /Ac  ««; /;mrs.— 355  white,  34  colored     Tl.o  mf      ^     ,       , 
wlMte  in  the  admissions  to  the  wards  is  allnit  17  ''"'""'  '' 

Nationality.— Americans  (exclusive  of  col..r«l^  77    n 
»^;  ''<'I<'H,  8;  Irish,  7:  En<rlish    5.  i!,      •         '^^'  ^^  >  ^'ennans, 
"oiH-nian„  3;  Welsh,  1.        "       '  ^'  S-«cl,navmn,  4;  Russian,  3; 

/w//,e.s;.ri;mr.s'.— Americans,  154 -Germans  114    J  ■  u  ^^    ^ 
;M5;8cotch,2;Welsh,l;Se;Klin     ~^^^^^^ 
12:  Russia.,3;  Italian,!;  Syrian,  1 ;  Fi„;  i'.  '^"^''''^'  Bol'em.ans, 

amity,  2.  •^'     '       ^  ^^  ^^^^y'  '^  >  sixty  to 

I'or  Ike  m-  (/ra/-,9. — Five  to  Mtoon  'io .  «a 

':-  • >.  203,'  tl,i,..,  ,0  ;„,*;"52    fo,     „X  .6^^  ,"^"""'^ 

«lyt..«.venty,6.    More  tl,M  „,  p  l!    f   f .,  ^'      '  "fj"  <"  »'«?,  8; 

l>m!iijbor,  3.  '  ^^aoDer,  25;  JNovember,  18; 

281 


I 


1  I 


I 

'     *    i 

;     1    ; 

1  1 

.    iji 

-mam 


282 


William  Osier. 


For  the  six  yeors.— January,  16 ;  February,  9 ;  March,  5 ;  April,  1  1 ; 
May,  9  ;  June,  14  ;  July,  42  ;  August,  74  ;  September,  69  ;  OctolaT, 
65;  November,  52;  December,  19. 

Locality. — Far  the  six  years. — From  the  City,  303  cases;  from 
Baltimore  county,  50  cases;  from  Maryland,  outside  Baltimore  county, 
14  ;  from  outside  Maryland,  18  ;  from  steamers  and  doubtful,  4. 

Mortality. — In  the  5th  year  eighty-one  cases  were  treated,  with 
five  deaths— a  rate  of  6.1.  In  the  6th  year  seventy-nine  cases  wviv 
treated,  with  seven  deaths — a  rate  of  8.8.  Of  the  one  hundred  :iiul 
sixty  cases  considered  in  this  report,  twelve  died — a  rate  of  7.5. 

For  the  six  years. — Of  three  liundred  and  eighty-nine  cases  treated 
to  May  15th,  1895,  thirty-four  died— a  mortality  of  8.7  per  cent. 

For  the  five  years  since  the  introduction  of  the  Brand  method,  tiirw 
hundred  and  fifty-six  cases  have  been  admitted,  of  which  twenty-j^ix 
have  died— a  mortality  of  7.03  per  cent. 

Of  299  bathed  cases,  20  died— a  mortality  of  6.6  per  cent. 


cl),5;  April,  11; 
er,  69 ;  Octolicr, 


30!)  cases;  from 
Jaltimore  county, 
doubtful,  4. 

ere  treated,  witli 
'-nine  cases  wcic 
)ne  hundred  ami 
rate  of  7.5. 
nine  cases  treated 
8.7  per  cent. 
nd  method,  throe 
vliich  twenty-j-ix 

per  cent. 


...^SPEOIA.  ^-i^ATORKS.  mrPTOMS  ANB  COMPLI. 

By  WILLIAM  OSLER,  M.  D. 
'.-ANALYSIS   OF  THE  GENERAL  SYMPTOMS 

l~J^\f^^^-~^'''^-n^ot,  were  noted  in  119  cases 
Total  for  the  s,.v  year^.^Zn,  81.7  per  cent. 

PEcnLiARmES  or  the  IU,SH.-(a).  Hannorrha.le 
.lames  M.,  aged  22  (Hosn.  No  779aN     n       i    ••" 
i>n.rnse  on  the  ahdonien  -u  d  In,'.!     r    l  '''^'»>'««'»»  tJie  rash  wa.s 

The  eruption  was  ahnni:  thl:     C'  1^:^  '^  ^  ^ "^^ 
severity.     Recovery.  ^ '""^'^ack  was  of  moderate 

b»n  a,-ca  ,he«ize  of  a    IvTI,  aHr"',"^''^"'"'''"  'P*-  ""J  '^ere 

b.  .a.™  ..lace.     I„  iilrj^^ ^  :^';t  X""",'  "'™"*"«^ 
spots  are  seen."  ^^"  '''^''^'  ecchymotie  rose- 

ti. ''3:^f  •;:'^  irarr:r  ^"  r  r  -'  -  ^'^^^  - 

a'-ndanton  the  arms.     Tie  sits  ^".7.        1'"'  *'*^^  '''  ^^^ 
more  ha^morrhagic,  and  a  si  In    "^'""''^'^"^  ^^e  4th  have  become 

left  costal  border=in\hem  d^x    ar^;fn:TH^^"  '''''''''  '''^'"  ^'^^ 
a'so  upon  the  posterior  axillary  fold!"  "  "'  ''"""^'^  P^^^^^"* 

Michaels., aged  22 (Hosp.  No.  11392^    Tha.,.    . 

283 


284 


William  Osier, 


ill 


numerous  on  the  upper  part  of  the  chest.  They  were  present  also  un 
the  arras  and  a  few  were  seen  on  the  thighs.  On  the  10th  spots  dt' 
simple  purpura  apjieared  on  the  skin  of  the  right  shoulder  and  ot' 
upper  arm.  On  the  11th  many  of  the  rose-spots  on  the  abdomen  wire 
htemorrhaglc  and  did  not  disappear  on  pressure. 

Jesse  T.,  aged  28  (IIosp.  No.  1 1861),  admitted  January  19th,  IS!'."). 
The  attack  was  severe  and  the  fever  was  high.  Tlie  eruption  was 
profuse,  and  on  the  abdomen  the  spots  became  luemorrhagic. 

(6).  Riish  Persistent  while  Patient  Afebrile, 

John  G.,  aged  21  (Hosp.  No.  84G1),  admitted  on  10th  day.  The 
temperature  was  105°,  with  unusually  abundant  rash,  of  a  deep  lowe- 
red color.  The  temperature  i)ecame  normal  on  the  21st  day.  <  >ii 
Noveuil-  .  xd,  the  23rd  day,  v  lion  the  temperature  had  been  iKirmuJ 
for  36  ;,-•>:,  fresh  spots  appeared  on  the  abdomen.  On  No\iinl)t'r 
Qth,  tiiv  /{*>i!!  day  of  illness,  there  were  fresh  rose-spots.  The  rectal 
temperaiurc'  had,  in  a  two-hourly  record,  only  registered  99.5°  oiKr, 
and  once  1(0°  since  12  midnight  on  November  1st.  On  XovcinlMr 
9th  the  spots  of  the  6th  had  faded. 

Charles  S.,  aged  25  (Mosp.  No.  8930).  Mild  primary  attack ;  scvore 
relapse.  Hash  abundant.  During  the  3rd  week  of  the  relapse, 
■while  the  temperature  gradually  fell  from  100'  to  normal,  fresh  spots 
appeared  on  the  abdomen,  and  on  the  23rd  day  of  the  relapse,  when 
the  morning  temperature  had  been  normal  for  five  days,  the  spots  were 
still  visible. 

(c).  Anomalous  Distribution  of  Rash, 

Augusta  A.,  aged  48  (Hosp.  No.  3168),  had  a  very  mild  Mttack. 
The  spleen  was  easily  palpable.  There  were  no  typical  rose-spots  on 
the  abdomen,  but  on  the  arms  and  hands  there  were  many  slightly 
raised,  red  spots  looking  like  those  of  typhoid  fever. 

id).  Exceptionally  Profuse  Rash. 

August  G.,  aged  26  (Hosp.  No.  11119),  admitted  OctolxT  lltli, 
1894,  about  the  end  of  the  3rd  week  of  the  fever.  The  tenipt'ratiire 
was  high  and  all  the  features  of  the  disease  well  developed.  On 
admission  the  rash  was  exceptionally  profuse  over  the  entire  trunk 
and  on  the  shoulders  and  arms,  and  very  thickly  set.     On  the  loth 


Special  Features,  Syntpioms  ami  rom,Mcafiom.  286 

the  spots  had  extendecj  down  the  nn.w  ..„,!  <• 

0"  .1.0  neck,  a  .unnbc-  could  be"       ./hm"''  V'  '"^'  ""^  •^'"" 
none  appeare,!  on  the  face.  ''"^'''''  "  ^""  ""  ^''«  '«g«; 

(r).  Pc/mnata. 
Tlie  only  cases  were  as  follows  :— 

.lames  E.,  aged  32  (flosi)    \„  •n(io\      i    •..    .    , 
^v.■.■k.    There  were  wcl  -nn   -..I  ^  -^l^'^),  n.hn,  ted  the  end  of  the  first 

flank  two  steel-granlClur^  '''''■''''''  ""^'  ™  ''^^  «'->  o^'  tLe  loft 
Carl  JV.,  aged  25  (IIosi)  No  9fi'■>'-,^  I.    i  .      . 

of  demonstrating  two  cases  •—  v  oi.  v  ;  ,,„  t|,e  occasion 

ia.j  »"..o  ,.„s  „po„  «.„•,.  iJenccC'u"  ;;":,',;;;■;'  ;'":= 

o»as«,nal  ..cciirreiuK  uiti,  ,K.,liciili      0,l„,,    i  ^  '   ""'"' 

l'>".l.,  .■lain,  ,|,„  „„,  ,,„',  ,7  '   ;,  2™  •*'""7.  7«i-lly  li.e 

.inilarl,  tl,c  Hiouli  pubi,;        "U'^.r  l"' ,';"''  '"°''°  '""- 
tl-  l-li.»li  or  ti„ir  „L  ™,  lib  ,,1    f  I  ;.""  "'"  "I"""  '^'''"' 

<a>.«  of  (v,,l,„iJ  fove,.  in  wl.J   .1,1      r  "  "'°''"°''  "■'  '"  "'« 

* ;  ea.:  !„,.„«  .o'l:':::;:::,i:  ::::;-::•;'— ^^^  -■- 

There  are  at  present  hi  c'  T  '''"'^'"*^*'  ^^■'■^''  '"^^^'^'''U- 

dice  and  a,  ot"!    «lT  I"  '"  T'''^;  ""  "'^'^  -^-rhal  Jaun- 
"oither  case  i      he^   a^^^^^^^  '"'"^''"^'■^  ='"''  -'Pl'-Vsen..    In 

are  numerous  st  e  Ir  !  s     !     "tf  ^7'"''-^^"-'  '"'^  '"  ^^o^''  there 

inner  sides  of  tldgls..Kl  "fr'  '""  *^"  ''"^''«'»^"'  ^''-«^. 

both  the  nedie,     J  "      ''''''''  •^"  *^«  '"''"«  «°d  J^gH-     In 

ent    J„  both  e.       M  "^''  ''''''''  ^^''  ^'"■^"'  ^^^^"^'''•^••s-  are  pres- 

1.- !  0  tri:  d^:^r' -^'^f  ?' ;-  ^"^^^'^'^^'  ^-^  •-  "^^- 

appear  to  hav"  c    s  d  n  u  I'!-      ""  '""'  "'  ^''^^^-    ^'-7  do  not 

caused  much  ,rr>tat.on ;  neither  patient  complained  of 


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286 


William  Osier. 


itching  nor  are  there  marks  v/f  much  scratching.  Indeed,  I  find  tlint 
one  patient,  formerly  an  Austrian  soldier,  is  quite  indignant  at  tlie 
removal  of  both  hair  and  i>ediculi.  He  tells  me  that  they  are  m- 
sidered  as  bringing  luck  to  the  bearer,  and  each  sells  for  from  5  to  10 
kreuzers  among  the  soldiers.  They  had  been  carefully  carried  by  liim 
for  ten  years. 

Crocker  states  that  "Moursou  in  18G8  wrote  concerning  the  fingor- 
nail-si^ed,  steel-gray  spots  of  pigmentation  (maculae  cerulcae,  taclies 
ombrecs)  which  are  frequently  seen  deep  in  the  epidermis  of  the 
affected  areas.  Duguet  in  1880-82  showed  that  this  pigment  was 
contained  in  the  thorax  of  the  a.iimal,  opposite  the  anterior  pair  of 
legs,  where  there  are  known  to  be  taro  pairs  of  salivary  glands,  and 
it  is  probaWe  that  the  secretion  is  conveyed  into  the  tissues  through 
the  haustellum.  Jamieson  thinks  that  the  stains  have  some  antestlietic 
eifect  as  far  as  the  itching  is  concerned."  In  this  patient  the  lnrhc'i 
bleudtres  stand  out  plainly  against  the  somewiiat  jaundiced  skin,  and, 
as  can  be  seen,  are  most  numerous  in  those  positions  in  which  the  podi- 
culi  were  most  abundant.  The  pigmentation  seems  to  disappetir  after 
the  skin  containing  it  has  been  pinched  for  a  few  seconds. 

n. — The  Fever. — In  119  cases  the  thermometer  registered  104° 
and  over  (rectal  temperatures),  Six  cases  only  had  a  temperaluni  of 
106°.  Forty-nine  cases  had  a  temperature  between  105°  and  1(16°, 
and  sixty-four  cases  a  temperature  between  104°  and  106°.  In  no 
case  did  the  fever  reach  107°. 

Of  the  eleven  fatal  cases  during  the  5th  and  6th  years,  the  liigliest 
temperature  recorded  was  106.3°.  Nine  had  fever  above  105°. 
Case  Susie  B.,  given  fully  on  page  345,  had  a  low  temperature  during 
the  greater  part  of  her  stay  of  9  days  in  the  Hospital.  The  highest 
record  was  103.4°,  and  there  were  only  a  few  hours  in  "liieli  the 
temperature  was  above  103°.  In  the  case  of  A.  B.  (p.  468),  tlie  tera- 
peratare  was  104°  on  admission  tc  the  v  ard,  but  at  no  time  subse- 
quently did  it  reach  the  bathing  point,  102.5°,  except  just  before  death, 
when  it  registered  104°. 

For  the  six  years. — Of  the  389  cases,  there  were  271  in  which  the 
thermometer  registered  104°  and  over.  In  only  one  case  was  tlic  tem- 
perature 107°.  In  14  cases  the  temj^erature  was  106°.  In  118  cases 
the  register  was  between  105°  and  106°,  and  in  147  cases  tlie  fever 
was  betwee'     04°  and  105°. 


Special  Features,  Smwioms  ,nu1  o       r      ■ 
III, — The  Pulse .Tl 

■  °"'y  2  ™  i'  "ore  than  160  ,^r  lllj^.^  '"''*■  '"'""'=''  '«■ 

IV.— Diarrhoea Ii,  41  pa.p„  ...„  i 

^'-•e  -e  at  son.  ti.„e  or  Xdllw^^  ::;:;"-^  ^  ^^  -- 
movements  in  the  day-n.oderate  diarrlue.  J,;  «'  ^'  '1^"^'  ''  ^«"^ 
"'•  more  mov^enients  in  the  ihy~exc,..;.n  r      >        '''  *''^'^  '^^''^^  '^^^ 

The  condition  of  the  bowel  in  t k  7m  ''"• 

-von  the  diarrhea  was  ,"^  ,    ^       ^1      ""  ""  " '^""^^--■» 
bowels  were  regular.  '     '  *'"''''  excessive,  in  two  the 

For  the  six  year^-.— The  hnwol^  ,.       1 
^30  per  cent.     L,  36  of  ^tj^;;;: ''"''' ^^ ''' ^-^^^  of  ^eS89- 
"HKlerate  or  slight.  '"ovements  were  frec,uent ;  in  81 

.>i^:;Itn.f^r;;;^;:;;:;:;^^^^ 

relaxation  of  the  abdo.nfna  t  I  .f  ■,  P'^''^"'^^'«"-  ^^^'^1'  ordinary 
organ  can  be  felt  ^X^t^:^''  of  a  nuxlerately  enlarged 
the  splenic  re,,ion,  the  Ingers  we  1  1  I  1 "'  7''^'  '^'  ^''''  ^'«-'  «» 
pain,  pressing  towards  the'r  ^  \,  f  ll'  :"!'  T^'^^  ^^-rds,  the 
'leep  breath,  and  the  fingers  of  Ih  1  /''?  ''^  '''''^  **>  ''-"v  a 
border,  will  feel  the  edge  of  the  s n l  f  T'  '"''  ^"^'"^  ^''^"  ^^^^^ 

over  the.n.    When  the  f  bdon     a  t"   J  ""''"""'  '""'  "'^'^^^ 

to  palpate  Just  as  the  mnscl         Lr     d  ITr  '''''f'''''  ''  ''  ''''''^ 

yet  the  border  of  the'organ  c     'd  lottfV"'  ""'  "'""""''  '^"^ 
ti.e  abdominal  walls.  *  ^'  ^''*'  «^^'"g  *«  the  tension  of 

For  the  six  years.—Jn  244  of  fJ,«  oon 
was  palpable.  '^  '^'  '^^^  ^««^«  ^^e  border  of  the  spl^„ 

2— RELAPSE. 
Tliere  were  five  oases  of  relaose  in  a.  ^.1 
"'  the  6th_fourt^n  cases  i7tr  ?''/'"''  ""^'  »'»«  ^«es 

per  cent.     The   total  Tu,    ^  t  T    ,""'"'  ^'"^  '^'■^'^'  '•  ^"^  ^.7 

nine,.ases  was  thirty-twolsV pe    It  "t,    '"  '^  ."''    ^'^'•*^- 
"ot  included.  ^      ^^"^-     T'^e  <loubtful  cases  are 


288 


William  Osier, 


Theresa  H.,  aged  24  (Hosp.  No.  8594),  admitted  November  9tli, 
1893,  at  the  end  of  the  third  week  of  fever.  The  temperature  fell 
gradually  after  fourteen  baths,  and  was  normal  on  the  17th.  TIkio 
was  complete  npyrexia  from  the  17th  to  the  26th — 9  days.  On  the 
26th  she  had  meat  for  the  first  time.  The  fever  rose  that  eveniiii^  to 
100.5°,  and  on  the  evening  of  the  27th  to  102°.  The  fever  persistod 
until  December  14th — 19  days.  The  range  was  102.5°  to  104..'}°. 
There  were  a  few  spots,  but  the  spleen  was  not  palpable.  The  tongue 
was  furred.     There  was  no  diarrhoea ;  no  complications. 

George  S.,  aged  34  (Hosp.  No.  8787),  admitted  September  i^iJth, 
1893,  on  the  14th  day  of  the  fever.  The  attack  was  severe,  and  tiic 
temperature  did  not  become  normal  until  October  21st.  It  reni;iin(d 
normal  until  November  2nd — 1 1  days,  with  the  exception  of  10  lioiiis 
of  pyrexia  on  the  24th.  On  the  2nd  he  complained  of  abdominal  pains, 
and  there  was  some  distension.  The  topgue  became  fiu'red,  and  the 
patient  felt  badly.  From  the  2nd  to  the  loth  the  fever  ranged  IVdiii 
99°  to  102.5° ;  the  spleen  again  became  palpable,  but  no  definite  loso- 
spot.s  were  seen.  There  was  .slight  diarrhcea.  From  the  15th  to  the 
19th  there  were  oscillations  from  normal  to  101.5°,  and  after  the  liJtii 
the  fever  did  not  rise  again. 

Christopher  T.,  aged  32  (Hosp.  No.  8049;  itted  August  2Stli, 

1893,  on  the  22nd  day  of  his  illness.  The  fever  was  intermittent,  and 
we  thought  it  might  po.ssibly  be  malaria,  but  the  blood  was  negative. 
The  spleen  was  easily  to  be  felt,  but  there  were  no  spots.  TIk'  tem- 
perature on  admission  was  103.5°,  and  for  the  first  four  days  ranged 
from  99°  to  103°.  From  September  1st  to  the  9th  it  was  normal— 
10  days.  From  the  morning  f  S'  ptember  10th  to  noon  of  the  l.'itli 
there  was  a  gradual  rise  to  104°.  The  fever  persisted  until  the  25th. 
The  spleen  was  readily  palpable,  and  there  were  doubtful  rose-spots 
on  the  skin  of  the  abdomen.  But  for  the  relapse,  we  might  have  lieen 
in  doubt  as  to  the  nature  of  the  original  attack,  which  (in  the  Hospital) 
consisted  of  four  days  of  fever  without  rose-spots.  An  interesting 
point  was  the  existence  of  a  characteristic  typhoid  odor,  which,  with 
the  history  of  three  weeks'  illness  c^nd  the  enlarged  spleen  (together 
with  the  absence  of  malarial  parasites  in  the  blood),  seemed  tn  settle 
the  diagnosis. 


I 


I  November  9(li, 
temperature  fill 
;he  17th.  Tiurt 
9  days.  On  the 
e  that  evening  to 
le  fever  persist(>d 
02.5°  to  101.:!°, 
ble.  The  tongue 
ons. 

September  29tii, 
s  severe,  and  the 
1st.  It  renuiincil 
Jtion  of  10  hours 
abdomijial  |)!iins, 
i  furred,  and  the 
;ver  ranged  from 
;  no  definite  rose- 
\  the  15th  to  the 
nd  after  the  19th 


:ed  August  28th, 
intermittent,  and 
od  was  negative, 
pots.  The  (cm- 
four  days  ranged 
it  was  normal— 
noon  of  the  l-'Stli 
tl  until  the  2oth. 
ibtful  rose-spot,s 
might  liavf  iieen 
(in  the  Hospital) 
An  interesting 
dor,  whirii,  with 
spleen  (together 
seemed  to  settle 


;i2  baths  before  the  temperature  ^oM  1  ,l'\^'  ''''^'^^>  «"d  he  had 
and  10th  tl,e  ten,perature  to  he  1  T  ""Y'^'  ^»  ^^'^^^^^  ^^h 
14th  there  was  a;yrexial^r;'tr;;1;"^  ^-m  the  11th  to  the 

iIh'  15th  reached   103.5°       Tifo  V  ,    '"'  '"^'^'"''•e^',  and  on 

^  ■      i  iiL   lever   •"■•■    ■  •-■  >      -. «  .  - 


i-e  had  41  baths  in  the  rdapse"  Tlirf '"'   '"'''''.''   ^^^^-lOo",  and 

hve  baths;  ,e,u,,er„„„,,  ,,„«o  ,V„„,  loso!  JV  »'    tP'"™' *™"'^- 
became  normal  on  the  41st  dnv     v         .  *     ^''^  temperatui-e 

.i.«  4is,  ,„  .,,e  64,1,  day  T^~:^::-:;;;'''^7»'''-  ''"^'■'■*  •■»"■ 

20.1.  n  slight  rise  in  tompe™,  J  ,  '  ,7,2  , '''''';'*;  ""  "'"'^''^^ 
fever  ta  lOOo.  P,,.i„  ,vi.|,  J/, „1  ' l^  '  »"''  ^^"l  chilis,  with 
const,t„(,.,„al  ,.v,„p,„,„s  fVo,,,  Decen.tl  2     ,  ?'  ''*  '""'  *«"> 

#%..    Pain  in  al,<l„n,e„,  IZ  an    ,°      "T"     '"''  '■""''"'''^^ 

a<t.'nstic  spots,  l„,t  the  to..s„e  was  L,™I  I  .,  "'"  "'''"'  ""  '*'"'- 
of  .!»•  l-atient  was  that  of  t™  ,„",""  Tl  "">'™"-"'  »"'"<i<"> 
.i.ai  ....  April  23„,,  jnst  si;,!:„nl'X  iiX,'""  "'  '""  "«- 

TI,e.o„,p„,.at„.„  ™ge  .v:^,it:n X'o!  04o'"'iT''>-  <■';-»,"«>■""• 
...».k;»l  ...fl..e„ce,  and  eaeh  tin.o  rednced  the  'te        "'        ""'  "  ""^ 

01-  siilHiormal.    On  the  cvrni„„  „r .      ,  -  ,        '""""  '°  "»"nal 

»«..,  .he  feve,.disapp     e ,    "Sf,   :    ""•'  '>'\'"'  '^X afte,-  a<l„,is- 

-  «..-.«l,  the  spiel,  was  re^^i;    lal ',:,  7'""°^  ""  ""«- 
s|.o.».    TI,oi-e  was  a  distinct  di,  J,!  '         "'"°  ""'■^  "»  '■"*- 

'Kv.  .i.e  ten,peratn,-c  was  ™  nnT  T|  1  ,'  ""  "" ,"'"'"•  ''''"■  "'-<=" 
<k'  -M.I,  ho  sat  np  i„  i,e,l  J  j  ,,n  H^  o«T  r",""'''  ""'  '»  f*-  «.. 
a...l  28,1,  the  te„,';,e,.a;:r4e   o    02«     'n'  '?*'  """'•    «"  "^  ^''l" 

o-...othand.,,,,..J-:;:--^;;^^^^^^^^^^^^ 


290 


WiHicnn  Oxler. 


resumed.    Tliero  were  no  rose-spots.   On  tlie  9tli  day  of  the  relapse  tli.' 
temperature  fell  to  normal,  and  tlie  convalescence  was  uninterrupted, 

Cliarles  S.,  aged  18  (Hosp.  No.  lOolT),  admitted  July  .'30tli,  18!i|, 
on  the  8th  day  of  the  fever.  The  temperature  rose  to  1()()°,  and 
remained  high  for  several  days.  From  August  3rd  to  6th  he  had  in- 
voluntary movements  of  the  bowels,  with  blood  in  moderate  amoiuit-. 
There  was  no  diarrhrea.  He  improved  rapidly,  and  on  August  7tli 
the  evem'ng  temperature  was  normal.  Then  for  six  days  the  tempera- 
ture was  between  98°  and  99°,  on  the  8th  and  9th  reaching  on  sevenil 
occasions  100.5°  and  101°.  On  the  10th,  11th,  12th  and  L'Jtli  tiieiv 
was  practically  no  fever.  In  sixteen  hours — from  4  a.  m.  to  8  p.  ni. — 
on  the  14th  the  temperature  rose  from  98.2°  to  105.6° — nearly  ei^lit 
degrees — without  a  chill.  He  had  had  egg  that  day,  and  his  mother 
had  given  him  a  piece  of  banana.  The  fever  persisted  ;  the  toiivmc 
became  coated  and  dry,  the  spleen  enlarged,  but  no  rose-spots  ai)]i(';u'wl. 
From  August  15th  to  September  :in\  the  patient  had  irregidar  fever, 
after  tlu  i  .^l  lew  days  of  a  markedly  remittent  character ;  there  wero 
daily  variations  of  from  three  to  five  degrees.  The  convalescence  \\,;s 
protracted,  and  he  did  not  leave  the  Hospital  until  September  27tli. 

Ella  C,  aged  11  (Hosp.  No.  10658),  admitted  August  Iltli,  1.S9), 
on  the  7th  day  of  the  fever.  To  August  24th  she  had  thirty  batiis; 
the  temperature  range  was  103°-104°.  The  spleen  was  enlarged  :  iin 
spots.  From  the  24th  to  the  28th  the  temperature  fell  gradually. 
For  six  days  there  was  no  fever,  except  for  a  kw  hours  on  the  niDrii- 
ingof  the  2nd,  when  the  thermometer  registered  101.5°.  On  the  4tli, 
5th  and  6th  the  fever  rose,  and  on  the  morning  o<'  the  7th  rcuehecl 
104.2°.  The  baths  were  resumed.  On  the  13th  the  temperature 
touched  normal ;  then  for  a  week  there  was  an  intermittent  ibver, 
with  excursions  from  97.5°  and  98°  to  100.5°  and  101°.  From 
September  23rd  to  October  3rd  there  was  a  daily  slight  fever  to  10U°. 
In  the  relapse  the  spleen  became  palpable,  but  no  rose-spots  were 
noted.  The  diazo-reaction  was  well  marked  in  the  relapse ;  it  was 
not  present  in  the  original  attack. 

Maggie  W.,  aged  IS  (Hosp.  No.  11070),  admitted  October  7th, 
1894,  after  an  illness  of  one  week.  The  temperature  was  irregular, 
""nging  for  the  first  tiiree  days  between  99.5°  and  103°.     Shortly 


itter  admission  it  rose  to  104.5°. 


After  the  10th  it  fell,  and  »n  the 


July  .^Otli,  IS'.il, 
jse  to  10()°,  aii,| 


i2th  touched  normal.     Tlio  smIo,.,.  „ 

.lian-hcva;  the  dia^o-reaction  l!  s  "  "  ""/"''"'^^' '  there  was  no 
-■re  donbtful.  Fro,u  the  I3th  to  ^t•en'b;  •  l". ""'  ''^^' '  ^'""  ^''^'^^ 
'.'lere  was  apyrexia,  and  the  i.atienf  u-.  ■  /■^^-■"^eventirn  davs- 

1"^  gained  in  weight  and  las  look;:;''::;":  "j;'' '^  "'''''' ''''^•- 
.November  Ut,  the  temperature  rose  to  m^  '      '^^   ""•'"■■^^''^ 

2,Kl  was  10;}.5°.     T|,o  fever  ke»t  I ,/         ,'  '"''  '''''  '^  l'"  "'•  ""  <l'^" 

f'^'Mhe  spleen  was  not  el,^!":':;:;  '^^'— -'iar- 
(liazo-reaetion  was  not  present  !„  ';  T  ''""'  "''"'  ""<*  t''^' 
'•'-araeter  of  the  first  attaek,  the  eon,,,  eh!  "  ."'"•'"•■^'  "'"  ""'^^'  «''<' 

'7'-  ftver,  its  persistence'/;,;  Z^^J'''''^'  l'^  ^-'-'  -set 
•alo.oenee  give  a  picture  unlil<e  anv<^"        :  !"    "'^'  '-"'''^'^  <-.- 


vak>seenee  give  a  nictn,.p  „   V  ""•^■'  =^'"'  "'^' 

fe've     p.ctuie  unhke  anything  but  a  rela,,se 

EvaM.,aged25(Hos„  No  lOBOfn     ,    .      , 
«l.e  was  a  Lithuanian,  a  nd  eoi  iS'l'        f'  '^''^""'"-^'-  ''^^^>''^^- 
-'">  lert  her  at  the  H^spitaH  t    vT  7T""'  ^  '"'^  ^'^  •— 

weeks.    From  the  10th  L  the  22n       ,:  ""'  '''  '""  ''^''  '-'  ^-> 

times  above  the  bathing  point  (1095;;  ""p/''"^''' "'''>•  t''''- -"  tour 
reaction;  doubtftd  spots  were  seen  •  tZ      i  "'"'  ''  '^"'"t  'I'azo- 

were  no  abdominal  syn,ptonsTh  .:!'""  ""  ""^  ''"'i'^'''^'"  tl'e.e 
^7'  -d  the  tongue  at'fi.t  was  cJ  t:  '^  f^  "'^  '""  ^''  T'"'^'*' 
at  the  base  of  the  left  lung,  with  rile.  nnT  ■'  "'''  '''^''^  ^'"'"^^«« 
"ogative.    Fron.  the  22ndVo  t      4  1    ,"  ""?  ''"'*'^'"^^'-  '^P"^^ 

tl'en  a  rise  gradually  to  104°  ;',\  'T" ''^'"■--^^•^•- ^'^'^s; 
Tl-ere  were  no  spots  /  the  s,^een  ",  if"  "  ^  ''''-''  *'"-^'-- 
diazo-reaction.  Fever,  in  rZ  I  t's'!  !  '  ^^"  ""^  ='  ^-'"^ 
were  the  only  symptoms.  '''^'""  "'"'   ^'"•^l  tongue 

Charles  \V„  ai^ed  '>I  /'W  \-  , 
1804,  about  the  ^nd  ll  ^Zr^l^''^'  ^^""'•""^  October  2nd, 
ranged  between  103°  and  104°  th,  "'"■  '^''^'  ^-"P-'ature 
'"arked ;  the  spleen  was  palnablen'n  t"'''  '^'"'  *''^  ^'-^^''^  ^vere 
"-->'•  O"  the  11th,  12^^  :i"3  ;:;;'^^^'''  ^'-^  ^-^P-atnre  was 
97°  and  99°.  On  the  Hth  it,  ^  temperature  was  between 
to  10.3°,  and  then  f^  l^  ^f  ^U  f  ?"^  ''''  ^  ^'-'-»'  "- 
102.5°  and  103.5°.     The  f  ver  d  T""'^^  temperature  between 

were  no  fresh  rose-spots    th!  "  '  ""'''  ^''^  ^^^''^     There 

was  coated.  ^  '''  ^'^^  '^^'"^  ^^^«  Pa'pable,  and  the  tong  e 


r.  j 


292 


Witlidm  Osier. 


John  S.,  aged  20  (colored)  (Hosp.  No.  11102),  admitted  Octolxr 
9tli,  1894.  He  had  been  ill  for  four  weeks,  hut  he  was  so  dull  ml 
stupid  that  it  wasdiifieult  to  f^et  any  accurate  information.  Until  the 
morning  of  the  12th  it  was  not  thought  that  he  had  a  specific  fever, 
as  the  temperature  did  not  rise  al)ove  99.5°.  Fo"  the  next  week  it 
ranged  from  99°  to  103°-104°.  The  tongue  wjis  furred;  then;  was 
no  diarrlKca,  but  a  diazo-reaction  was  oresent.  Tlie  spleen  was  not 
palpable.  Tiie  fever  fell  slowly,  and  by  the  ;5Ist  the  teniperatinc 
was  normal.  For  five  days  the  morning  and  evening  records  wcw 
below  99°  ;  then,  on  the  evening  of  November  4th,  tlie  tomp'M'atuic 
began  to  rise,  for  a  day  or  two  not  reaching  beyond  102°,  antl  ou  the 
8th  and  9th  touching  103°  and  104°.  The  tongue  was  furred,  but 
the  spleen  was  not  palpable.  On  the  Tith  the  temperature  was 
normal;  on  the  13th  and  14tii  there  were  slight  rises,  and  snl)S('- 
quently  the  temperature  remained  normal. 

This  patient  may  have  been  admitted  in  an  interval  between  two 
febrile  periods,  lie  looked  as  though  he  had  had  an  illness,  and  the 
muscles  were  weak  ;  but  his  tongue  was  quite  clean,  and  tlier.'  were 
no  abdominal  symptoms.  Subsequently  an  interval  of  five  days  sepa- 
rated two  periods  of  fever — one  of  nineteen,  the  other  of  seven  davs. 

William  H.,  aged  28  (Hosp.  No.  11212),  admitted  October  •J.iid, 
on  the  18th  day  of  fever.  The  tongue  was  furred,  the  spleen  was 
enlarged,  but  there  were  no  spots  and  no  diazo-reaction.  The  attack 
was  mild,  and  by  November  4th  the  temperature  was  normal.  On 
the  oth  it  rose  slightly,  and  then  remained  normal  until  the  l.'llli— 
eight  days.  From  mid-day  on  the  13th  to  the  24th  there  was  t'l  vor 
of  slight  range,  not  rising  above  102.5°.  The  tongue  was  furrctl,  the 
spleen  was  enlarged,  but  there  were  no  spots.  There  was  no  diazo- 
reaction,  and  the  patient  had  no  abdominal  symptoms. 

Albert  G.,  aged  31  (Hosp.  No. ),  admitted  February  5tli,  1895, 

about  the  10th  day  of  the  fever.  The  attack  was  severe  and  typical; 
he  had  thirty-tive  baths,  and  by  February  21sl.  the  temperature  was 
normal.  He  sat  up  in  bed  on  March  2nd ;  out  of  bed  on  the  4tli. 
The  temperature  remained  normal  and  sub-normal  from  Fchruary 
21st  to  March  13th — twenty-one  days.  On  March  13th,  1  Ith  ami 
15th  the  temperature  rose  a  fraction  of  a  degree  each  day,  reaching 
102.1°  at  10  p.  m.  on  theloth.     On  the  16th  and  17th  it  once  or 


''^P^cial  Feature.,  Syn^plo,,,  „„,^ 
twice  tiiicJied  102  5°  onrl  ♦,  •  .  " 

-^  '"rrcd;  there  were  no  alZ^ J     "''''' ''''''^^^^^'    ''^'"e  t„n,M, 
was  felt  in  the  o-i^ina,  attae^  :  Wd  i^X'^''  '  ^''^  ^'"-'^  wl'.^ 
'-V  «...spu,.ous  spots.    The  eon^les  1    t  "  I     '""'' '  ^''"'^  ^^-^  a 
-"'l'''""-J  -f  a  general  te.ulen.e.ss  of     ,  ''';    ''"  -^'"■''  -^^'^  ''« 

The  days  of  apyroxi.  w..        r  „  ""'  ''''"''  ^^'''^  """"^f- 

7.  -3,  5  8,  21.  One  case  ha.l  two  well  „,  i  ',  '  "''  -•^'  ^  ^  -^.  ^7, 
-nterval  separated  the  ori.in-d  ■  u  "  '■'"'"•'^^"d  relapses;  23  days' 
.lays  the  first  and  second  ^^T  '"'  "'"'  '•^■'"''-'  -<'  4^ 

KkLAI'SE.— DOUHTFUL   Cases. 

Charles  S.,  aged  25  (irosp.  No  89'lnN      )    • 
For  ten  .lays  the  feverwas  Lyth^t  tf  r^        •'"""'•^'  ''^''  '804. 
po.nt.     The  spleen  was  ^alpahlT;  d  t  ""'  '•"■''  "'<'  '-''""g 

There  was  no  diarrhea.  ()  tl  'i5t|  r7,r;'''  ='  ''^'^^  — P"^' 
l--t"re  tonched  nonnal  and  ro  n  l  '  ^"'  ""'  '«^''  ^''«  'en,. 
iOl  °.  Then,  from  the  19th  to  tie  '  h"""'"'^  '^  '''°  =""'  '""•<"  ^o 
1^°,  and  the  patient  heean.  In  d  ^  ^^^  ^^  V^^^^'  --'^  to 
not  present  nntil  after  the  lOth     Tl.       .  ^^'"^  *''^^'>-'-«<cti,  .    v^s 

s..m.ssive  crops  of  rose-spots     The  Z,!  '"^'"'^''^  "'"'  ^''^'''e  U".  '-e 
•'"til  Fehrnary  5th.         ^  ^"  '^"'"i''-''-atu.e  did  not  reach  normal 

h\  this  case  four  davs  of  n         i 

Hoiry  L.,  aged  20  (Hos,,.  jf„  „„„,  .      ;' 

»1  J  -  ....  o„  May  7.1,  the  to,  ,S,':^ '';'"'»■   f^'"  «™l„„|,  „„d 
..'el.l  .1  rcmamcl  „„r„,„|     o„  .1,1  "'''""'•     ^'."il  1'-'  nn,l- 

»  «.»<.  a..»  a  period  of  l,p,  ,  1 :;«    "'J™'"'''  "•'■'■«  .• ; 

LeaJad,.,  >l,o.e  were  „„„|,'|„,    ,  7 '^""''"'S^'i  Le  <-on,plai„«,  „f 


204 


Will  id  III   (hlcr. 


Kniilo  (J.,  a>?wl  It  (Hosp.  No.  10;W5),  admitted  July  9tli,  18!»l. 
iSeVfiv  attack  ;  scvonty-thrtr  baths  to  Jtdy  28tli.  Kidarpcd  spleen; 
no  definite  spots  ;  no  diarrlujoa.  From  July  28th  to  Au^;ust  1st  the 
temperature  was  between  100°  and  101°,  falling  once  below  normal. 
From  August  Ist  aecession  of  fever — 104°-104.5° — baths  causing 
drops  to  !>8°  and  97°.  High  and  persistent  fever  of  nine  days'  dilu- 
tion; spleen  enlarged;  distinct  rose-spots /'oy  the  jird  liiiw.  From  tlii' 
9th  to  15th  of  August  gradual  I'all  of  fever  to  normal,  followed  hv 
uninterrupted  convalescence. 

Walter  J.,  aged  26  (ITosp.  No.  10426),  admitted  Jidy  19th,  18!M. 
'riic  patient  was  a  soldier,  and  had  been  in  bed,  in  hospital  at  Fortress 
Moiu'oe,  for  thirty-two  days  with  headache,  fever  and  weakness,  hut 
he  had  not  had  diarrho'a.  When  admitted  his  temperature  was  !»!)°, 
but  in  the  evening  it  rose  to  nearly  103°.  The  edge  of  the  splci  n 
was  palj)able,  but  there  were  no  spots.  From  the  19th  to  the  2")tli 
the  fever  only  twice  rose  above  102°.  On  the  21st  there  were  snnic 
suspicious  rose-spots.  From  the  25th  to  August  11th  the  fever  wiis 
higher,  103°-104° — and  ho  had  baths  steadily.  The  spleen  was 
enlarged,  but  there  were  no  fresh  rose-spots.  The  diazo-rcaetiim. 
which  was  not  })resent  on  admission,  became  well  marked.  ( )n  AiiLnist 
1 1th,  r2th  and  part  of  the  13th  the  temperatm'e  was  below  100"  most 
of  the  time,  and  the  tongue  became  clean  and  he  felt  better.  I'lorii 
the  13th  to  15th  the  fever  again  rose,  and  until  vVugust  2ii(l  kept 
between  103°  and  104'^,  requiring  constant  baths,  of  which  ho  had  to 
tiie  latter  date  ninety-four.  On  August  17th  typical  rose-spots  wiiv 
seen,  and  they  recurred.  The  tongue  became  furred,  but  the  general 
condition  kept  good.  The  diazo-reaction  was  present,  and  the  spleen 
remained  large.  From  August  2nd  to  12th  the  lever  fell  slowly  to 
normal.  From  August  13th  to  October  3rd  the  temperature  ranged 
fi'om  99°  to  100°  and  101°,  and  twice  rose  for  a  few  hours  to  between 
103°  and  104°,  the  last  time  on  October  4th,  the  day  on  which  he  sat 
out  of  bed. 

Counting  the  time  in  which  the  patient  was  in  bed  at  Fortress 
Monroe,  the  fever  lasted  one  hundred  and  ten  days.  It  is  very 
probable  that  on  admission  he  was  in  an  interval  between  two  attacks, 
though  we  do  not  know  that  the  fever  had  been  down  for  any  length 
of  time.  The  three  days  from  August  llth-13th  separate  dearly  two 
febrile  periods  in  the  Hospital,  and  in  the  interval  the  tongue  clearal 


IjL 


July  lOtli,  18!M. 
■^pital  at  Fdrti'css 
1(1  weakness,  luit 
)oratun>  was  !M)°, 
\iTO.  of  the  spleen 
lOtli  to  the  I'otli 
tliere  were  sdinc 
til  the  fever  \v!is 
The  spleen  wus 
le  diazo-reaetion, 
ked.  On  Auirnst 
below  100"  most 
It  better.  l''rom 
Uigiist  2nd  kept 
which  he  had  to 
il  rose-spots  wvw 
,  but  the  geiioral 
it,  and  the  spleen 
ver  fell  slowly  to 
iiperature  ranged 
hours  to  hetweeii 
y  on  which  he  sal 


ween  two  attacks, 
i^u  for  any  length 
)arate  clearly  two 
lie  tongue  cleared 


•Vem/  Fmfure.,  s,,nj,(o,n 


uiid  he  looked 


'"  "'I'l  (hmn/, 


III  srze. 


"iiioh  better.     'i'|, 


'iiij/ic(ifin)is. 


iM  ri()(is 


I'o  c«He  belon^H  („  a  group  „/ 


'^I'l'^-M,  however,  did 


29/5 

not   reduce 


of  hijrh    ( 


f»!)°  to  100°  an.l  loi 


IJohert  R, 


«ver  ai'c  separated  I 


P"U'';"at  interest,  hMvhici 


)V 


'"tervals  of  mihi 


'  two  or  till 


'ee 


Vyvoxm  of 


;'^-'2''(irosp.Xo.n%-.3,,ad 
'f'"layofhisfi.ver.    Tl... -.' 


fS!»o,on  the  14th  day  of  | 

•     ,.week-]04o_io/i./i°.     He'hi.d  I 


'J'i 


"'  '<''iip'^''ii(ui 


niittwl   Feh, 


nary  3rd. 


aiiitc 


pleurisy,  with  eff, 


)ath 


«  and  then 


■0  ranjr,,  w^s  U\^\^ 


'<■•'  SIX 


CllllScd    IK)  SVIll 

I"  March   ilih  th.  ,, 
tlic  isth  the  i'ever  fell 
(late  fell  below  99°       i 


:''^---'<'«m.hiaiiv(LL!!^^ 'I' ••••-' 


llfTf 


A 


An 


fro  was  coiitim,„„,s  f 


"'sappciin.,!.    I 


nun 


KTadiiall 


'ever.      I{,,t 


'iiission,  but 
•Vbruary;in| 


y>  and  ,,„  t|„,  , 


fcnipcriitiire  at  some 
«!•  100.5^  ill  the  aft 
to  March  flth, 

OIK 


''••^"'  the  1 8th  t(»tl 


iv  w 


J>art  oftho  (1; 
"•""•     Then  followed 


''<*  niornii 


en 


IS  below  99°,  but 


\v '■("'.  the  loth  and 

'""■"'■"J,'  "f  (he  latter 

'  'K  '>f  (he  24th  the 


'■<»>'<'  to  100° 


n  which  there 


spilt 


■'• 'caching  102.5°.    Thosnl 


\V'as  a  mild  fever— ior)° 


'»  period,  from  the  24th 


no  f/iazo-roaction  in  tl 


'}>ieendi,l„„t,.„j3,,^,^..jj 


to  102°. 


-only 


^.snoleucocytosis.    The  pleural 


dad  no  diarrli 


ell 

or 


^'a.     He  had 


lie  urin(> 


efr.i 


7;'^7'-''t-''ernessofthe       r\^ 
(lid  tieno.-m<?   r. ..      . ..  .         '      *''a 


He  had  a  fe 

'«*;»' K'-adually<|i.app,;a;„, 


Here  were  no  rose- 
AV  sweats.     'i'| 


■soreness  of  the  legs,  of 


the  period  from  the  1 


IHTatiire  touched  normal 


^th  to  the  24tl 


It  onl 


V  a 


ier(! 
He 

"  \f'n-  indefinite 
prolonged  Ivsis 


,  separa^"  the 


",  during  which  t| 


"'•'gi'ial  attack  f 


lie  teni- 


'■»'"  a  relapse  ? 
3.-P0S...VPH0.  ...v,,,,,3  ^^  ..MP.H...,, 
'"  eleven  cases  there  were  weli-marked  .        • 
l^'ratnre  during  convalescence     I'lit  ''''  '^'''^''''^^ -^ tem- 

fiist  Report.  '''•    ^^'S''^^'^"  '"Stances  were  given  in  the 

Vase  AXV.— Aueusta  R     „     i   .^ 

'«"  b"amc  normal  „„  ,l,e  07.,,   ''=,°'  "'".  """'  ''Wk.    Tlie  tenmcra- 
*■  l.aJ  done  very  well      olCtrr^ri  ""*"  ^"'-">-'  "'I 

'"*".«.    The  fever  fZ  ";    r  !"  oT ' "'    T.  ""''  ""  '^^<o.uZ 

-^%..eva«on.  ..,,e:r.r;::xr;t:;r 


! 


•     I 


A 


296 


William  Osier. 


no  rose-spotH.  She  convalesced  slowly,  and  wna  afebrile  from  the  1  lili 
to  th(^  27th.  She  sat  up  on  the  17th,  and  on  the  '26th  had  solid  f'ooil. 
The  bowels  had  been  a  little  relaxed.  Tiie  temperature  rose  on  the 
27th,  and  on  the  three  following  days  remaine<l  between  101°  and 
103°.  There  waa  slight  abdominal  pain,  particularly  on  pressure,  in 
the  right  iliac  fossa.  On  ()cto!)er  Ist,  2nd,  .'Jrd  and  4th  there  uciv 
slight  oscillations  of  temperature.  Tlw  spleen  did  not  enlarge,  iiml 
there  were  no  rose-spots.  The  abdominal  tenderness  disappearcil. 
The  convalescence  was  very  slow. 

Case  A'A'.— Emil  E.,  aged  1!»  (Med.  No.  3225),  admitted  at  tl,.. 
end  of  the  firs*  week.  On  the  20th  day — September  10th — the  tem- 
perature was  normal,  and  remained  so  until  the  15th.  He  had  Immm 
constipated.  He  had  not  had  full  diet,  but  had  had  milk  toast  on  the 
13th.  On  the  15th  the  temperature  rose  to  102°,  and  for  Hv(!  dav.f 
ranged  from  99°  to  102.5°.  The  tongue  was  clean,  the  abdomen  not 
tender;  the  spleen  had  not  increased  in  size,  and  there  were  no  s|K)t<, 
On  the  2Ist  and  22nd  the  temperature  was  normal,  and  he  was  given 
solid  food  on  the  morning  of  the  23rd.  In  the  evening  the  tom|)(ni- 
ture  rose  to  105°  without  a  chill,  and  remained  high  all  night  in  spite 
of  two  cold  baths.  By  6  p.  m.  on  the  24th  the  fever  had  disappeared. 
and  remained  normal. 

Case  XXI. — John  R.,  aged  45  (Med.  No.  3484),  admitted  Novem- 
ber  15th,  1893,  in  the  3rd  week  of  his  illness.  The  temperature  for 
the  first  i'ew  days  was  not  iiigh,  but  he  subsecpiently  had  thirty-eight 
baths,  and  on  December  5th  the  fever  had  gone.  He  sat  up  on  the 
17th,  and  gained  in  weight  rapidly.  On  Jaimary  1st,  without  a  chill, 
the  temperature  rose  to  104°.  He  had  complained  in  the  evenini,'  ut' 
pain  In  the  side,  but  there  was  no  fever.  "  This  morning  he  complains 
of  a  catch  on  the  right  side  when  he  takes  a  deep  breath,  and  on 
auscultation  there  are  a  few  fine  crackles  at  the  end  of  inspiration." 
The  fever  kept  above  102°  on  the  1st  and  2nd.  On  the  moiiiini;  of 
the  3rd  it  was  normal,  but  rose  to  103.6°  in  the  evening.  After  the 
4th  he  had  no  fever.  The  local  signs  at  the  right  base  did  not  t  xtcnd, 
and  he  made  a  satisfactory  recovery. 

Case  .YAT/.— Florence  M.,  aged  22  (Med.  No.  3406),  admitted 
October  19th,  1893,  on  the  6th  day  of  the  fever.  The  attack  \va« 
.severe.    The  temperature  fell  below  100°  on  November  6th,  ami  from 


""•'""".  ««''n...|  .s,,u-,.c.Iy  to    nstif    V       ;""'  '''""*^'''  ••'■  ^■■«'"  .lays' 

;"'l"^r-^'"-^-'-  fn,:j;'':^;f-,f^''.  an., .;.,,;: 

wit/i  tlie  pain  in  tlie  Jen-  ^^^"^  "''''-* 

Ch.veA'A'F:— CeeiJiaS 

'"''"■'•  «''"'  J«9^-     St've;;^.     ?^'T''-  ^'^'"  ^''^^^)'  -l""-«cc.  Sen 
""•.^^  't'll  to  norn,.,l         u    ^"*^''^'  prolongs    fever      Tk     ,     '  ^P" 
Mffn     •  i.V  '  ""  ^^,>femlH.r  27tl,      o    .7  ^"^  tempera- 

*vo.„  98,5°  „„,!  ,00.50,    rf"  "■  f "  ','»™g  '■■■>ng«I  f„r  ,„.„  „J° 
0  10.,5    ;j„,|  re,„ai„«l  belivm.  lon'o     j  ,     ""■  '™|Kralnre 


298 


William  Oslo'. 


fluctuations  botwcen  normal  and  100°.  The  tongutMvas  clean,  the 
bowols  i-egnlai',  anil  nothing  was  found  to  account  for  the  three  davs 
of  Ibvor. 

Ca,sr  A'A' 1 7i.— Harvey  S.,  aged  25  (Ho.sp.  No.  10975),  adniiii,,! 
iSepteniher  26th,  1894,  at  the  end  of  the  ilrst  week  of  fever.  \un-  a 
week  the  temperature  ranged  high,  once  nearly  to  100°,  hut  tlniv 
were  no  s|K'(!ial  features,  and  on  October  otii,  (Jth,  7th  and  8th  ih,. 
temperature  touched  normal  each  day.  On  the  morning  of  the  ,si|| 
the  iever  rose  u)  102.5=,  and  on  the  !)th  to  104°.  There  were  exadlv 
forty-eigiit  hours  of  iever,  after  which  it  disappeafed  completely. 

The  case  is  interesting  since  a  period  of  four  days  in  which  tli,. 
fever  was  not  contiiuiously  normal  was  (idlowed  by  what  aijpcaivd 
to  l)e  a  very  characteristic  post-typhoid  recrudescencic. 

Case  A'A'17i/.— Ciiristopher  T.,  aged  19  (Hosp.  No.  llOO!)),  ad- 
niitted  October  l.st,  1894,  in  the  third  week  of  the  fever.  The  lever 
fell  on  the  10th,  and  he  entered  upon  a  satisfactory  convalescence. 
On  the  2Sth  the  fever  rose,  and  on  the  29th  reached  103.5°.  On  th,, 
evening  of  the  ;30th  it  fell  to  normal.  The  rise  Wi.s  due  to  a  foin.iihu' 
tonsillitis.     Streptococci  were  obtained  in  pure  culture. 

Case  A'A'/A'.— >.richael  S.,  aged  22  (Hosp.  No.  11392),  n.lmitled 
November  14th,  18!)4.  Tlie  attack  was  .severe,  with  high  ievei'.  Tlir 
lysis  was  protracted  for  about  fourteen  days — from  Novembei-  2Stli 
to  December  llth  ;  the  temperature  remained  between  99°  and  102  . 
On  the  mornings  of  the  llth  and  12th  it  was  normal.  .Vt  8  p,  ni, 
on  the  12th  the  temperature  was  100.5°.  During  the  morning  di'tlu 
13th  it  rose  to  103°,  and  throughout  the  day  ke|)t  high.  On  the  14tli 
it  remained  about  101°,  and  fell  to  normal  in  the  evening.  It  did 
not  rise  subsecpientl)-  above  the  normal.  There  was  nothing'  (oiind 
to  account  lor  the  elevation.  It  is  interesting  as  .separated  hv  a  vorv 
brief  interval  of  apyrexia  (scarcely,  indeed,  for  an  entire  dav)  f'idiii  a 
very  prolonged  lysis  after  a  severe  attack. 

4.— TYPHOID  FEVER  AND  MALARIA. 

A  careful  examination  is  made  of  the  blood  in  everv  patient  with 
fever  admitted  to  the  wards,  without  which  some  of  the  cases  of 
autumnal  malarial  fever  could  not  be  differentiated.  A  full  aiialvsi> 
of  our  malaria  cases  for  five  years  has  been  given  by  Drs.  Thayer  and 


J'i 


''"'"' ^"'-'- ^.,^^..  .„„  a.^,,,,,_„       ,,^ 

jr^'-f  --,^-"  tlK.  sa.no       :, ^^^'7^  ^''•«.  vieinit,  a^  ^ 
'''■'""■f  <>"  fypl'oi.l  fovc-  thoro  was  "»'ntione.l  i„  our  first 

;:  «'-Y";>..,i. ,,.., ,.  ,.,,,^ .  ; ,  ^  ';;V"i''---.  '••  one  ,..o  in 

'"'•-"•/'•-I  occnrrcl  before  the  Ja        )  ""'  "■'^■^^'""  -'"fi'  tl.o 

'"  f".  followinfT  n.n.arkal.Ie  ''''^aj.peare,!. 

'■'""■■""ons  malarial  fever  .-1  ''''"'  '"''*"''  ^•>'''''"'''  ^''-'vor  fbllowed  a 
Kate    f.j  ao-ed    'i]   (]\    .      v 

."'^  Pat.ont  was  admitted  Sentend  U  """  '•' "'^  ^'How.s - 
'•'""^  ;"  /'-  '-1^  and  .ides,:  ":.''';'  T'  """"l"--..  of 
-;-'y  >..  Fobrnan-,  i8.4.  '  She  |^  ^  ''",  'T^  '-'arial  f^er 
=""^'^«|'-<>';g-  "''■'  '''^  ■■'  '••'1'^^  been  very  healthy 

^r^p^^^'l^l^^  ''^'.  -^'.  i'oadaehe  and 

S  e    as  had  nansea,  h„t  has  onl v  ^S  7'  ""'  '"'" '^"^'  ---^- 
;'«-'^'  -me  on  snddenly  when  sh  "1       /'"VT  ^-"-  *''"-•     The 

'-'...•nation  of  the  blood  i„    he        j'"  '""'''^  ^•"-  -'"^'  tin.e'    T  " 
^•-  o..  adnn-ssion  was  nearJv  IO40  '      ""'"  ''"''  "^'«"^'>«-     Ten.pera- 

•^'.^Mvas  a  large  framed/stont  woman      T 
;7';" '""•!>-;  pnlse  soft,  not  d  eZ      ..f  "^'- -'--^  ^lean ;  there 

O'l  the  30tli  and  Oct.,bp,.  .  .  f .  ^'"'- 


H' 


300 


William  Osier. 


V    ^ 


!   , 


marked  intra-cellular  amcjeboid  hyaline  body.     On  October  Ist  tlie 
temperoture  reached  103°. 

On  the  2nd  tliere  were  perfectly  characteristic  hyaline  malarial 
parasites  seen,  each  containing  small  fine  pigment.  Quinine  was 
administered  on  October  2ud.  She  felt  very  well ;  temperature  gradu- 
ally fell,  became  normal  on  the  4tli,  and  on  the  7th  she  felt  w.ll 
enough  to  leave  the  Hospital.  On  the  7th  it  was  noted  tliat  the 
blood  has  been  negative  since  the  2nd,  and  that  no  crescents  luul 
developed. 

The  organisms  present  were  those  associated  with  the  irrci;ulai' 
autumnal  malarial  fever. 

On  admission,  November  6th,  the  temperature  was  104°,  and  idsc 
in  the  evening  to  106°.     She  was  a  well  nourished  woman,  a  trifle 
pale ;  rational ;  pulse,  120 ;  respirations,  30.   There  were  well  inaikcd 
rose-spots  on  the  abdomen,  and  the  spleen  was  enlarged  and  palpable. 
The  blood  examination  was  negative.     On  the  6th,  7th  and  8tli  the 
fever  was  high,  rarely  falling  below  104°.     From  the  liistorv  we 
were  in  doubt  as  to  the  nature  of  the  disease,  and  baths  were  nut 
begun  until  the  7th ;  they  had  very  little  influence.     On  the  9tli  she 
had  grs.  xv  of  Quinine,  hypodermically.     At  4.30  p.  m.  on  the  7th, 
when  the  temperature  was  105°,  she  had  a  chill,  not  severe,  tiio  only 
one  during  her  stay  in  hospital.     Until  November  14th  the  lever 
kept  continuously  high,  rarely  going  below  103°,  even  after  the  hatlis, 
She  was  drowsy,  the  tongue  was  furred,  the  rose-spots  charactoristie, 
and  the  spleen  enlarged.     The  blood  examination  showed  no  changes, 
On  the  12th  and  13th  she  had  slight  diarrhoea.     From  the  14th  the 
fever  was  less  intense,  and  on  the  19th,  after  the  forty-sixth  hath,  it 
touched  normal  for  the  first  time.     On  the  22d  it  rose  again  to  104°. 
From  the  24th  to  the  27th  the  temperature  was  normal ;  at  S  a.  iii. 
on  the  morning  of  the  28tl',  the  temperature  was  99.4,  and  during 
the  day  rose  to  103°.     She  then  had  a  continuous  fever  for  .six  day.s 
the  maximum  temperature,  104.7°.     She  had  no  chills,  no  sweats 
The  general  condition  was  good.     The  tongue  was  clean  ;  the  niiiul 
clear;  there  were  uo  abdominal  symptoms;  the  spleen  coidd  not  he 
felt  and  there  were  no  rose-spots.    The  diazo-reaction  was  not  present, 
From  December  4th  to  the  7th  the  temperature  was  normal ;  then, 
until  the  27th,  there  were  daily  irregular  elevations  to  101°,  102°, 
and  103°,  usually  in  the  afternoon  between  4  and  8  p.  ra. ;  the  morn- 


J 


3n  October  Ist  tlie 


witli  the  irretriila: 


'W  ...w,  ,„,„,  „„„  ^ 

mg  record  being  l^i;,,,.  ,„„„  """ 

""■»  te  general  e„„dm„„  ,1'  ^'^  f  ^  'l;e  20,1,  l„|„„  990.     „ 

Most  careful  examimtio,,,  „„.  „"a     f  !""^  "'"'<"■  '^a,,  tl,e  fever 
™  «.„„„.     After  ,l,e  27,    ,  ett      /'"  '"^ '  '»  -ga    In  J 

Digestire  System. 

(«).  I'akotitis. 

The  only  instance  among  the  IfiO  .         ■ 

It  was  really  the  development  of  tlHs  V-  ^"''"'  '"^'-^  ^^  P-  '345 
d-agnos.  The  clinieal  'lia^nosL  i  t  .  u"'''""  "'"■'^''  -^^gesL,  tie 
^urat.on  before  admission  ;  rnodlrato  f  "'  ^^^'^"^'^'^  ^^ ^'vo  weeks 

or  muscles  of  neck  and  of  Zt  Z  '  '"''''''  '^l^'^"  '  -^ 

Jl'^aneons  hyperesthesia  and  In  LroVr^t'''''^^  ^^  ^i^'-^'" 
1^'ood  ,n  the  nnne;  no  dia.o-reaeHon    f  .f"'^-^ '  «"'all  amount  of 
nonna   temperature;  parotitis.  '  '"'  '^'"'^  ^'«>-  "^ofore  death 

-'«  f/ie  .vx  years Fivp 

<»*.  "Mel,  ,vi,l,  •„„,  ,■;  27]°Ty  '■"  "'■=  P''^'°'"  »ne,  „f  229 

"^f  :t;;rr:,r'-» -■--■  ™.e  ,r„.d  ..^^ 

I'l  most  of  the  cases  .V  ,  -n  i 

-^  '•"  "0  -e  did  th;  f :  t:i:i';;''^';.^ 

lumorrhage.  ^^""^^  ^""ow  directly  upo„  .^^..Jl^^' 

111  the  previous  series  H.o..„ 
-  the  ,..entage  ^l^  1^::^^:  ^T' '  ^  ^'^  ^"  ^'^e  389 

OlafJ.,  aged  24  (Hosp_\o.  7992) 
and  lug]  fever      W^  i    j  i       •'•^''•';-     A  severe  case  w.M, 

"-■  r '-a, ™":i't :: ,r;rr-  °" ''-^'!' err 

P'«bl„„J,  „„d  ,„  ,  ,!,„„,,"  *',,''='•  "«  Pa'ien.  passed  250  co  „I 

■ "  ""  <'"'rrhM  after  it.    X|,e„ 


I'^lliiiiji 


I         I 


302 


William  Osier. 


was  no  reduction  in  the  temperature,  and  the  general  condition  \va« 
not  aggravated. 

Alice  C,  aged  18  (Hosp.  No.  7602),  on  the  16th  day  of  an  attark 
of  moderate  severity,  after  the  32nd  bath,  passed  a  stool  contaiiiiiiLc 
clots,  not  very  abundant  and  not  large.     Slie  had  not  had  diarrlma. 

Charles  H.,  aged  31  (Hosp.  No.  7955),  on  the  23d  day  of  a  so\oiv 
attack,  after  the  eighty-second  bath,  passed  a  stool  in  which  wtiv 
about  1  iv  of  clotted  blood.  The  bowels  had  been  a  little  Ioi.mj. 
The  hajmorrhage  did  not  recur. 

George  S.,  aged  34  (Hosp.  No.  8287),  on  the  17th  day  of  a  wiv 
severe  attack,  had  a  soft  movement  containing  clots  of  blood.  He 
had  had  diarrhcea  and  much  abdominal  distension.  He  had  a  vtiy 
prolong!  (1  attack  with  relapse,  but  there  was  no  further  liajmorrhagL'. 

Florence  M.,  aged  22  (Hosp.  No.  8448),  had  on  the  13th  day  a 
small  hicmorrhage,  which  was  found  in  the  draw-sheet.  She  had  had 
nodiarrhtca,  but  the  abdomen  had  been  distended.  As  the  next  stuul 
contained  no  blood,  the  baths  were  resumed  after  a  single  spongin;;, 

John  W.,  aged  24  (Hosp.  No.  9566),  admitted  April  3rd,  on  the 
8th  day  of  illness.  On  April  12th  he  had  a  soft  stool,  intimately 
mixed  with  blood,  with  one  or  two  small  clots.  Shortly  after  lie 
passed  a  second  stool  containing  still  more  blood.  The  fever  did  not 
drop  after  either  stool.  He  had  been  having  one  or  two  soft  move- 
ments each  day.  He  v,as  ordered  lead  and  o[)iuin  pills.  No  further 
bleeding  occurred.  The  baths  had  already  been  omitted  on  aivonin 
of  the  intense  bronchitis. 

Charles  S.,  aged  18  (Hosp.  No.  10517).  The  case  is  given  fiillv 
among  the  relapses.  The  attack  began  severely;  temperature  rose 
to  106°.  There  was  no  diarrhoea,  and  the  abdomen  was  nut  ten* 
At  3.30  a.  m.  on  August  2nd  he  passed  an  involuntary  stoitl  cuii- 
taining  biood,  with  very  little  ffecal  matter.  On  August  'M\\  lie 
passed  another  stool  containing  small  clots  and  dark  rcddisli- 
brown  material  On  August  4th  he  had  another  small  luemoi- 
rhage.  The  hfemorrhages  occurred  without  diarrhoea  and  had  ii« 
injurious  influence.  After  August  4th  the  temperature  fell,  and 
he  improved  rapidly. 


eral  oondition 


Homer  H.,  aged  2'    H        v 

J-n04o.  There  .a.  «  ^pio  f  orrr""^'''"^^''  ''^''--  103° 
'-temperature  had  been  below  the  b^t,  ''•  .^"  *''^  ^1^''  ^ncl  J2th 
'-•;l'gl.t  diarrh,.a  ;  then,  o,.  th  U  "f  '^r'  ''"  ^'^'"''--  ^^ 
A  ^  a.  m.  o„  the  13th  he  had  astoo  Z"  •^''''  ""'  ■'^^'-'  «-''  ^'ny. 
r  ere  was  „o  ,>ain ;  the  temperat  Xr'n  "'^'""^^  ""-  '^^-'• 
'''''  ^'"^  *^'»P^™t„re  fell  to  „Ual  l^Tli        T  '^"''''-     ^"  ^^e 

Joseph  M.,  aged  20  (H .       v  "  '^  ^'  "'^''  "^«-'->'- 

^^H  on  the  «t,fda;:iI^;lLf-^^fU  admitted  October  25th 
-g  and  .harrh^a.     The  temp^^tu^  r"^  T  ''''''  ^^^'^^  --i^" 
''^"•een  104°  and  105°;  often  1 1,  .      '"     '^''""^  ^^'^'  ^''^t  week 
^0  '-e  g.ven  in  the  twent;-fon;,I'  ,    T"",  """^"^  '^^'  '^'^^''■^  ^'a 
ro.e-,spots  were   abundant.      A      T'  „  ^^''^  ^'''^^'"  "'-^^  'a-'go  and  th 
•■'gl'teenth  bath,  the  patient  h.da  ,     '     "\   ""    ^'^«  29th,  after  the 
^";;f  bright  blood,\,ot  IS  \  d:;"'Tf  ^^^'^^'"^  '^'-'t  i^al  ^ 
'  ''"^  "«t  affect  the  temperatu  e    !  ^u^!''  '^'^^''^y  "'"t''  Pieces 
--103°  and  104.2°  .^.ti^t        X^t'''  ''''''  ^^'^^^^^^ 
g      hieechng.     The  abdon.en  was  not    IW      r,""  ''^  '''-*''  '"">tl^er 
o.>.htion  was  good,  though  the  toZT      .'"''''''  ''"^^  ^''^  general 
^'-  .^Oth,  the  stool  passed  at      u??      T  ^'■"^^■"  «"^'  ^^^^-'ol     On 
'-.V  l>lood.     The  stool  at  3  '  'n    rtf"."^*^  ^'^"*  '''  ^  "^^  ^'ark 
"'a"er,  but  no  blood.     B,  /,  "j;,?"  '^\'f'^  -obtained  dark  fav  l' 

'«"'  -^'  "e  made  an  u:;ii;::::;;::;::^;^;;;-i-.ature  tour; 


(c)-   I'erforation. 


Ill  tile  ])revious  series  tliP,v>  ■  , 

i»  •(■»;-.  „.,„,,„,;;;;;\;-Y«i.'  -lea.Ls  r,,„.,  „.r,Wa„-.,„, 
^<»' f he  SIX  yearn "^sq     "  .••^- 

'!»  6.al  cases.  """*  ""o  S-'.,,  a,  „.  473  i„  ,|„  i,'/"';'- 

;«*»io..  of  tl,e  b.,„.i  a,  d  tT'  r;r    '^""'  ">■"■"•"'"'  -Ws. 
« S™.«.ally  ,1,0  serio,,    fea„  ™    ,  ,!  '"'"'""  '''  *'»l«UeIj1l  ■ 

'«"'»ii».leHyi„g„„,„|i,i„„;"""''  'l-^W-ear,  a„d  we  are  i„  d,,,,^,  "j 

•^«";  t'trs'.?:  £r:efi°„;r^'  if"'  -""^  ^^o.  '«»^. 

"•     T''"  'eniperafure  ranged 


304 


Wiliiam  Oslei: 


from  102.5°  to  104.5°  ;  the  spleen  was  palpable,  the  rose-spots  wen 

distinctive  and  the  general  condition   very  good.      There  was  n 

diarrhoea,  an 

2d,  the  teinperutnre  was 

ing 


1st 


d  the  abdomen  was  not  distended.     At  8  p.  m.,  Augi 
s  103°,  and  he  had  a  bath  ;  and  for  the  folioM- 


forty-eight  hours  he  was  distinctly  better.     At  7  p.  m.  on  th 


nil- 


;}d  he  complained  of  a  sudden  pain  in  the  right  ^ido,  at  the  lower 
The  abdomen  was  held  tense,  and  there  was  tendernoss  on  pressure 
in  the  right  hypochondriac  and  lumbar  regions.  Duruig  tiif  ---lit 
the  patient  complained  but  little  of  pain,  after  a  hypodermic  injectiim 
of  morphia,  but  the  pulse  became  very  weak  and  rapid,  and  the  ex- 
pression of  the  face  was  noted  by  the  nurse  to  have  changed,  ami  lu 
seemed  dazed. 

On  the  morning  of  the  5th,  Dr.  Thayer  made  the  following  ikiIc: 
"  Patient  is  lying  on  his  back  with  the  eyes  sunken  and  rolled  up- 
wards;  the  face  is  pinched  and  drawn,  and  the  expression  vciy 
suggestive  of  peritonitis.  The  hands  are  cold  and  the  fingers  l)lur, 
The  abdomen,  which  was  previously  relaxed  and  sunken,  is  nuw 
distended,  and  the  nniscles  are  tense  and  contracted.  The  liver  flat- 
ness is  obtained  upon  the  6th  and  7th  ribs.  The  note  is  the  same 
over  the  entire  abdomen  on  direct  percussion,  and  on  auscultatorv 
percussion  the  '  tap '  is  everywhere  conveyed  directly  to  the  ear.  The 
pulse  is  128  and  small.  The  second  sound  at  the  base  of  the  heart 
is  redupli<'ated." 

The  temperature  was  104°  at  10  a.  m.,  and  through  the  day  did 
not  rise  above  102°.  There  was  no  diarrhoea.  He  had  profuse  sweat-. 
On  the  6th  the  fever  was  higher,  10a°-105°,  and  the  pain  was  still 
severe.  At  6  a.  m.  he  had  a  large  soft  yellow  stool.  He  was  given 
strychnia  hypodermically,  and  spirits  of  turpentine  by  mouth.  The 
facial  expression  was  better,  and  the  pulse  stronger.  On  Augu-^t  7th 
the  fever  was  lower  and  the  abdominal  i)ain  and  distension  imicli 
less.     The  perspiration  was  profuse. 

August  8th.  He  had  a  comfortable  night  and  was  in  all  respects 
better.  The  temperature  did  not  rise  above  102°  and  the  abdoiniiiiil 
pain  had  disappeared.  On  the  9th  the  serious  symptoms  had  had  all 
disappeared,  and  he  made  an  uninterrupted  recovery. 

Ambrose  B.,  aged  31  (Hosp.  No.  11310),  admitted  November  4th, 
at  the  end  of  the  2nd  week  of  an  attack  of  fever.     The  temperature 


'-"18th  there  were  only  one  or  twc^n!"'; '  ^'^  ''■°'»  ^''^  ^«' ''  ^«' 
i-  «"^'an  to  con,,,lai„  of  pain  i„  Z  T  '""'"'''  '^'^h'-  On  the  14th 
-.'if  out  beyond  sli^htsi-ene^tt^^^^^^^^  T'''^  '-'^'  ''o 

'--derabJe  distention,  the  soreness  "j     ''"  J''^  ^  "'^''^  ^'-'-  was 

le^Mvas  drawn  np.     r„  ehe  eveni.t    ,  '""'^'"''  *'""'  "^  '-'^''t 

=""'  "'«  l>"l«e  to  126.     He  had     ':  •       ^""''^'''"^'"•c  ''ose  to  ]05?5° 

'n-.nely  sensitive  and  tense  ivu^hV,,,  '''"''"  ^^'^'^  ^l'"'^'' ''"led  ex- 

'-pa^,ation  was  ve.y  di^^U  TS;:,.t/'^''^  '"^'^  ^^^  - 
at-l  .n  the  n.pple  ]i„e.  There  were  nl  H  "  ^"''^  ""^  "'>''^er- 
'""'-• ,  The  patient  was  extre  e  v  „  t  '"  '""^'""'"^'^  '""  ^'^  24 
l-'so  though  rapid  was  of  fai.  v  ,1,"  "''  ^'"'^^  '^tional,  and  the 
-".ata.  The  von.iting  had  eoasc  J.  "h""'^  ••'•''-'"'  ^'"■IK'ntine 
=''f-; ."aJ  <l'stension  continued,  he  had  'T^  ^'"■^^"  ''^'-^-  ^'^^ 

P"l.s.Ml.d  not  rise  above  120  no,  f      f  "'"'''''^"»'  voiuitin-.,  but  the 

'■';' l«t,,',n.ad  five  stools  ^nToThrrC^         t'''  '''''     ^^ 
olor  and  ,n  one,  on  the  18th,  there  I  "''''  '"'"  ""'^''  >'^^""^v  in 

^lood.  The  tongue  was  furre  but  n  T  ,  '"'  ■"'  ^''■'''^•'""  "^^  '>'-igl>t 
-<'  -'-H.SS  prevented  anv  I  Vatt  '  ■^■-  ''^'"'  ^--'  '''-^tensfn 
T':-  was  no  inereased  nwS  ^^t^T"-?'"'' "^' ^''-Wo-n" 
1-.A.I,  and  could  be  extend  d  T,:  Vt  ''^  ^^^'^  "-v  not  so 
""P'ovement.  The  fever  1  tt.ed  7  i"  T'  '""'^  "'^'■^  <'«-'-' 
a    o„„„a  pain  and  distension  werre^^^^^^^^^^  che,,,,^,  ,„,  ,,^ 

of  the  abdomen  had  been  above  the   nvel    .    1      ^'^'^'^''-'^-n^ent 
1'en.s  als.s,  were  seen  in  this  part      Pa   'r  '         .""  '^''  22n<l  c-oils,  in 
.'•««'''y  and  the  chief  re-^io  ,   '  f  ..      '       '"  '""'^  "'^"'  ^'  "'ade  n/ore 
Ti.e  temperature  fell  ..jj,;  ,^      ^^  ^  i"  tJ>o  right  iliac  W 
H.e  pat.ent  was  discharged  Janua^Stl  "'''''"'"'  -"valescenee 

r'le  intense  abdominal  mi,,   /  v 
-PKi  Pnlse  suggested  p^f^  h;' "  ^^^"'""'  ^''^  --t''%  and  the 
"'^'  ^aeial  expression  (.Ihich  Cf  „e.  e^^|•'""^  ^•""•''■^■■-'  '--ever 
,"^;;-"«  state  or'  the  patient,  the  abs  1     ;''""'' '^^'  ^''«  ^-^ren.ei; 

; :  'yr^^^-^>  -acie  us  doubt  t:xi:eL;  ;"^""'^-^  '^'--^- 


J 


m 


306 


Wil/iam  Osier 


Vascular  System. 

Phlebitis. 

Thomas  T.,  aged  36  (Hosp.  No.  8667),  on  the  35tl)  day  of  a  wrv 
severe  attack,  while  the  temperature  was  still  ran^inti;  as  high  as  103.5", 
began  to  conii)lain  of  pain  in  the  left  groin.  The  note  on  Decemlii  r 
22nd  reads  as  follows: — "There  is  tenderness  in  the  left  groin,  ami 
slight  snperfioial  redness.  It  does  not  appear  to  be  a  glandnlar  in- 
largoment,  l)nt  there  is  a  fnlness  in  Scarpa's  spaee.  The  vein  is  imt 
to  be  feit.  There  is  redema  and  pitting  on  the  left  tibia.  Hecaniidi 
Hex  the  left  tln'gli  npon  the  abdomen."  Snbseqnently,  a  cord  devcldpcd 
along  the  inner  aspect  of  the  thigh  in  the  position  of  the  long  sapluii- 
OHS  vein.  On  the  24th  the  superficial  redness  in  Scarpa's  space  piT- 
sisted ;  bnt  the  redema  of  the  leg  had  disappeared.  He  had  no  further 
trouble  from  it.  Tiiis  patient  had  diills  at  intervals  from  the  3i(l  to 
the  8th  weeks.  He  had  none  in  the  5th  week  when  the  symptoms 
of  thrombosis  were  present, 

John  E.,  aged  26  (Hosp.  No.  8509),  towards  the  end  of  a  rcliipM', 
in  the  sixth  week,  had  swelling  and  tenderness  in  the  left  groin  and 
an  induration  just  below  the  saphenous  opening.  Scarpa's  space 
looked  fuller  on  the  left  side,  but  there  was  no  swelling  of  I  he  let;. 
Movement  of  the  leg  caused  pain.  A  thrombus  developed  in  the 
long  saj)henous  vein,  but  did  not  extend  to  the  femoral.  lie  had  a 
slow,  tedious  convalescence.  There  was  no  aggravation  of  the  IIvit 
while  the  leg  was  painful. 

Theodore  B.,  aged  24  (Hosp.  No.  10298),  admitted  July  otli,  KS!I4, 
at  the  end  of  the  second  week  of  fever.  From  the  12th  to  the  15tli 
the  temperature  ranged  between  99°  and  100°.  On  the  evening  of 
the  15th  it  rose  to  104°.  On  the  I6th  he  began  to  complain  oi'  \y,\u] 
in  the  inner  part  of  the  left  thigh.  Tliere  was  no  redness,  mi  swell- 
ing, but  a  well-marked  cord  could  be  felt  in  the  course  of  the  iiiteinal 
saphenous  vein.  On  the  16th  and  17th  the  temperature  kejit  iip. 
From  the  18th  to  22nd  it  was  almost  normal.  On  the  morniug  ot 
the  22nd  he  had  a  chill,  and  on  the  26th  the  temperature  rose  again 
to  104°.  There  was  no  sign  of  redness  in  the  course  of  the  sai)lienoii- 
vein,  the  thrombus  in  which  could  be  well  felt.  The  general  condi- 
tion was  excellent,  and  he  made  a  good  recovery. 


'"  the  end  of  the  first  sn.k  oV  fll  ;     of  (  "'"""^"'  '"^y  ^'"^-'^  ' «» ». 
"a.s  l.el,nv  102°  and  J.o  was  in,:       " '^."^"•^^  "f'',  wlu.,  th.  fevn' 

--•<. '-  had  a  sudden  ;;• : '  ^i:;^,;"  -;7  -.y  am.,,  a  J::; 

;'"«1  1^-,C  were  swollen  and  tender   L  J  tl  ^" ,/"  "'"  ^•^"'  t''^'  t'">'' 
HUornal  saphenous  vein  eonl.l  l'  'fe      .   l'  ""^  '"'-^  '''"■^'-     'r'- 

""  '"^'rease  in  the  fever,  which  ren  ■        .'  r"""  '"'^'^''-    '^^''«<'  was 

'  ""^^  the  ,„ner  aspeet  of  the  thi.d       Wi  "'"  ■''"''  *"'<'"'•'-« 

''-I'Fared,  and  he  recovered  eon^petelv'  "  '"^  ^''-^^^  ''"'^  ''"d 


Respiratory  System. 


I'l-EURiSY. 

O'iset  of  Typhoid  Fever  with  Acute  Pi..    ■ 

'^'-'•■«y  '•«  not  a  fre,ueltc  ?"'■"■"■""''■'  ^'^-^^'o-U^Mi., 
^y^^^^^^.^^Z.'^T^^^^^-  The."w..: 
General  Hospital,  acute  pleurisy  was  .•''''''■^'■*' *''^' -^^<'ntreal 
:;-e.  The  oon,pli<,atio„  l  3l  ttj  "?",  '"■"^'  ""^'  -"Pven.a 
'"•■■^trates  the   forn,  of  typhoid  t'    •"    ^'"^  ^''^^  ^•'■'-  ^^^^'given 

-Imonts,     n^easles,  typhoid  feve'7)    snt.^  ^''"^''  •^^-'  '''•"'  -any 

^"■-  puberty  she  has   l,een  verv  well           "'';''   ^""'    ^"'^"n'onia. 

attaek  of  ague.  "•    '^'"'    ^^'"'   the  exception  of  an 
i'resent  illness      Viw         i 

-V"f  t  ^'^^"  ''^^^  -S^-dt.^:;^ ""  ''^^"  ^^^''"^  ^•^- 

"g".^i'elmdashakinLrchill   which T  ,7' '  ^^'^  "^''^'a-     Xine  davs 
;  '^'-1  „.  t,,er  a^l  2lS::f^  ^    ^  "'^  ^^  "'' "^es,  and  ..: 
'•;  "P  and  about,  but  she  had  .u^.sen  2    ^  t\  "^'  ^''"  ^"""fe'''  ^o 
^'-  ''as  had  a  slight  cough.      Yeste     '     "  "   "     '^''"^  ^''^'  ^''-^ 
■^e^-e'e  pain  in  the  left  side  (n.T       \      """"^^  ■^''^'  ''^^l  a  ve.-v 
'''■-tlO,andfeverand    ogh   Ir  l','"'"  "^'--^^  '^>'  taking  a    J   , 
«"  ^''--ion  the  tel^it   ;:t      r'^f"'^  f^^  ^°"^^  -''^' 
'•"^"^-'  32.     The  blood  exan.  ation  '    '"  ^"'^^'  ' ''^°'  -«!>- 

l'^--  ^-  »>•  ^""'  ••'-^  "^-«''ve ;  leucocytes,  1500 


Hi 


i     i 
1      ( 


i    t 


J 


308 


Williavi  (Mei\ 


Present  condilioii.  Tho  patient  is  a  licaltliy  looking,  well  nourished 
jrirl.  At.  the  time  of  the  examination  she  was  Hwcating,  and  eried  out 
a  ^rood  deal  with  pain  on  i)ein<r  moved.  Tiie  temperature  on  the 
niorninj,'  of  tl»e  22d  rose  to  104°  ;  the  tongue  was  eoated  and  red  iit 
the  edge's.  The  thorax  was  well-shaped  ;  tho  expansion  very  muri| 
more  on  the  right  than  on  the  left  side.  On  drawing  a  deep  hreatli 
she  complained  of  great  pain  in  the  left  axillary  region.  Percussj,,!, 
was  clear  in  front  on  the  right  side ;  on  the  left  side  there  was  modi- 
fied resonance  at  the  fourth  rib ;  below  the  fifth  rib,  and  extendiii;: 
into  the  axilla,  flatness.  Behind,  there  was  flatness  from  about  the 
angle  of  the  scapula.  The  breath  sounds  in  the  infra-scapular  rpi,n,,n 
were  somewhat  distant,  not  tubular;  no  rales.  In  the  lower  axilla. 
as  she  drew  a  deep  breath,  there  was  a  loud  fricti.)n  murmar.  At 
the  base  behind,  tactile  fremitus  was  diminished.  Only  a  small 
amount  of  gelatinous  s])utiun  was  obtained  ;  no  tubercle  bacilli  ;  tlu-re 
were  a  few  encapsulated  micrococci.  The  abdomen  was  smootii,  not 
distended  ;  spleen  not  enlarged.  Patient  was  ordered  warm  appli- 
cations to  the  chest  and  a  Dover-powder  at  night. 

On  the  23rd  and  24th  the  temperature  ranged  between  102°  and 
103.5°  ;  respirations  from  35  to  42,  and  the  movements  caused  o;iv;it 
pain  as  she  drew  a  deep  breath  or  coughed.  There  was  very  little 
expectoration  and  it  was  not  blood-stained. 

25th.  The  patient  looked  very  ill— more  so,  indeed,  than  is  usual 
in  a  case  of  ordinary  pleurisy,  but  there  was  no  evidence  of  any  addi- 
tional trouble,  and  every  day  rose-spots  were  looked  for  caivl'iilly 
and  the  expectoration  was  examined.  The  range  of  temperatuic  was 
liigher  and  the  prostration  rather  more  severe  than  are  comnn.ii  in 
simple  acute  pleurisy. 

On  the  2()th  the  temperature  ranged  from  103°  to  104.5°,  and  at 
this  morning's  visit  there  were  seen  for  the  first  time  some  distinct 
rose-spots.  The  area  of  splenic  .Uilness  appeared  to  be  somewhat 
increased  downwards ;  the  edge  could  not  be  felt  on  account  of  tlic  sore- 
ness on  pressure  at  the  costal  margin.  She  was  ordered  batlis  to-day 
at  70°  F.  The  condition  in  the  left  pleura  reuv-ns  unchanged.  The 
friction  rub  is  still  loud  in  the  lower  axilla  and  there  is  a  good  deal 
of  pain.  For  the  next  week  the  patient  had  the  well-marked  features 
of  severe  tyi)hoid  fever;  the  temperature  range  was  between  104°  and 
105°,  and  the  baths  had  very  little  influence,  rarely  reducing  tk 


^eciai  Feainr..,  Sym,to..  „«,  ^,^„,,„tion..  ,09 

ten.perature  more  tl.a„  „„o  .,r  tw„  doirreos     m 
'H'«H,  l,i,t  the  puLsi.  „.a.,  n.|,i,|   ,,„,  .     .1       .  '''''"""''  ™"«'<o'i«- 

f-  ''-■'-K'  l.a.l  r.i  ,,,i,,s,  1'  ,7  \''^'  '^'^  '•   ^^"  ^><''<''-  r.i;. 

!^"liy  H.ar  it  .as  thought  .;,lvlsaU:  :'h  "  ''^'t  ""'  '''''''''  ^ 

"'•t°.  ">Hl  ....  the  7th  he,an  to  ,  TT't  '"'"•■'■"  ^03°  an.! 

ti.e  fever  fell  rapidly,  a.ul  „„  tho  I  '\^\  '        '■'""  ""'^  "■"'^'  <'" 

The  condition  of  the  left  pleurrJ.u'ur. ''"'''"'  T"'  '■--'"^■''  «"• 
On  October  5th  the  bre.t  N,  ^  ""P.oved. 

On  theGth  it  was  noted  tl.nf  fi        ' 
"-  angle  of  the  seapnia.     F  v  .   n't'"""''  "'"'  '""  ^'^^^''^^  '-'-v 
"'  tl.e  axilla  the  iHetion  sonnr^^  r^:;:;;''^  ^^ ''i^^''-^  - 
"■as  not  so  tronldesonie.  ^  '"  '""•'•      J  '"c  eongh 

On  the  ]3th  it  was  noted  th-if  tl„     I   i 
aln.ost  disappeare,!;    the   fi tt  on    t  '       ""  "'  ''"  '"'^  '«-  '-' 
n.a.le  a  very  satisfactory       -o     1    ^     ''''''''^';,     ^^'^^^  ^LLs  .she 
--and  gained   hetLn^;:;^..:'^;;;/-^^^^^ 
Hi.™  she  went  out,  nearly  ninetee,.  ,.        7      '  ^^"venil)er  l«th, 

i--ted  nntil  the  Hrst  of  N^Z^Z      Z  "^'^''^-     '''^"  «-'^'-' 
'--  "as  practically  norn.al      I  k    '"';  ']'  ^•""'''■'-"  at  the  left 

rea--l  freely,  si.;  ,,,,  ,i  J',     f ,"'       !  "  "'"■^'"">''  ^^'"■^■''  ■^l- 
'ec^le  ..-ychniu  in  doses  of  a  t  i^yl^,  Jl^'^  ^^^^  -^-  -Pi^^  and 

It  ,s  interesting  to  note  in  this  cJ  ^•■'""• 

l'aHn'ng-56  baths  between  10  n  o.  H  ZT'  "^  *'"  ^•'^^l-'-t 
•2  noon  on  the  oth  of  October '  st'?, ''''  ^'^  ^^i"-"'-,  and 
-'^>-the  pleurisy  progressive  J  iL;,  '^'^^  :,"  ^--^^  "^  ^ve  a 
"g^^'avated.  The  condition  when  el  ,  '"  '"'^''  ^^'^^  ""^ 
-■'i'^al;  thusonthe3rdit  va  „  Jlf^^^^^^^  I"^  '^"^'''^  ^^-  verv 
f"'«^'  -as  160,  respirations  I  T  "  ,  '  ""  '^  ''"  '"^'^'^  ^'-^  the 
'•"tshe  took  the  food  and  stimulal  T  -T  ''""'""'""'^  ""^^  ^'n-; 
great  tenderness  of  the  t  Lt  e  1  '  '"''  ^"^''  *''^'  «'^^«  ^^-I'fo..  'of 
'-•..tcTupted  recovery  ^""-^J"--  of  the  baths  she  made  an 

•lc«fe  Pleurisi/  at  Onset. 
•lacob  G.,  aged  35  (Hosp.  No   101  ^QN      .    •      , 


!    I 


I  : 


li 


310 


Wiilidtn    (hlfr. 


no  particular  pain  in  tlu"  cliost.     Tlu'rc  is  a  ditt'iiH'  l)ri>iicliitis.      II, 
li;ul  a  mild  attack  ;  the  pleurisy  (lisappoarcd  in  a  lew  dayn. 

Avnfe  I'/inrix;/  with  IC(f'un!i>n  in  the  Thiid  \V*-ek\—S'o  SiimjitoiiiH. 

RobtTt  U.,  aged  'JO  (IIosp.  No.  11!)6:{).  admitted  FeWniary  ;{|(i, 
18!»5,  o»  the  14tli  day  of  the  fever.  The  attack  hud  l)egnii  with  a 
chill  and  nausea,  but  he  had  neither  cough  nor  pain  in  the  bide  On 
Fchrnary  5th  a  friction  ruh  was  noted  in  the  right  lower  axiliiuv 
region.  He  had  no  pain,  no  cough.  In  a  few  days  there  were  wdl- 
inarked  signs  of  einisioii.  On  the  12th  the  lino  of  dulness  heliind 
had  reached  the  angle  of  the, scapula;  an  exploratory  liineturc  hroimhi 
away  a  clear,  brownish  fluid,  which  was  sterile.  He  had  protii-c 
sweating.  For  the  fn-st  wL'ck  thi;  fever  was  liigii — 10;J°-10.')-.  The 
cifnsion  cleared  gradually,  and  by  the  time  he  left  the  Hospital- 
March  .'Ust — the  resonatK'e  was  only  u  little  defective.  Tlicrc  wi  iv 
no  symptoms  pointing  to  the  pleurisy. 

InTEN.SE   BltONCH ITIS. 

In  Caxe  XXVI  of  the  fatal  cases  the  bronchitis  was  so  intcn-i 
and   the  cvanosis   'occame  so  extreme  that   bleeding  was  cinplnvcil, 

Renal. 

Urink. 

In  Volamv  IV,  a  very  thorough  consideration  of  this  secretidii  in 
tyi)lioid  fever  was  given  by  Dr.  Hewetson.  The  cxaminatimH  uiv 
made  daily  in  the  sevcri  and  at  short  intervals-  ii:  li  e  mild  cii-i .. 
An  interesting  study  of  Pyuria  and  its  as:MV-i:iL'  d  mi  ■lo-orgaiiisnii, 
by  Dr.  Blumer,  will  be  found  in  another  part  of  this  ftiseiculii-. 

Albumin  was  present  in  1.39  cases.  In  only  five  of  these  was  it 
abundant;  in  a  majority  there  was  only  a  distinct  trace  with  the 
"sual  tests,  such  as  is  almost  invariable  in  the  fevers. 

T-.'r.'P  ('(tsts  were  present  in  Gl  cases,  usually  oidy  a  few  and  soiiie- 
limes  found   )-.Iy  after  the  use  of  the  centrifuge. 

There  were  no  eases  of  serious  nephritis  in  the  series,  such  a.^  were 
jiresent  in  the  first. 

Dictzo-readion. — This  was  present  in  118  cases — about  74  percent. 
Its  importance,  &c.,  are  fully  consideral  by  Dr.  Hewetson  in  \'ol.  IV 


IS  was  so  iiiti'ii!.c 
i;  was  cnipluyed. 


'  this  secret  inn  in 
oxamiiiatinii-  iw 
I  lie  mild  cnsi ., 
mi'TO-orj^Miiisiii", 
is  fasc'ic'iilii-. 

\,'e  of  tlicso  was  it 
ct  trace  with  tin- 
's. 

'  a  few  and  some- 
sries,  such  a.-*  \\i'i'i' 

■about  7  t  percent. 
•etson  ill  Vol.  IV. 


'"Special  Fenfinra    v 


.// 


"iiiplainiiij,'  o/ 


week' 


witli 


'''•'"■ili.ea  ami  /;. 


!»J()), 


I'l'  liad   11(1   I 
'eiiiperatiirc  oii   tli 


I't'a.laclu.,  ,|i,„.,.| 


';''"."■'""' •V'-;,„s,l,t,., 


^■';''-     ".- Iiad  l»,.|,  ill 


ueiiiorrli 


""••'.  'i'V.'r,  1,11,1 


H\y.. 


'«^'S  an.l    „„  ,,,„„,j(,^^^  ^. 


''  '  wealviic; 


"'    f'Veililljr  „f  jiil 


'••111    til,,  „ 


"•■  "early  tin 
III  (lie  ln.|K 


■cc 


«iis  dicrotic  l().s.      'pj,,.  ^.^^j 


satis/iictory.     Tli 
••""I  coiitaiiit'd  nil 


I      .     .  '^    ■    "le    llusc 

"'"*'^'""  r-.se  to  104^     Tli 


'"••  "■"•''  K«od,  and  hi 


Ik'  f'lilse 


'*;  "••'"<•  «.-Ht  |.assod"vas',.o  ■        ,  ^"""'■"'  ••'""'-'<"' 


I'f  the  Hpleei 
'"It  not  tuiidi 


''""""  and   ,,,..,1, 


to  I0;j 


«'er 


Oi 


"  ^^''M  palpal.l,..     '|'j_ 
Tile  /evi-r  for  tl 


'loi'fjd,  , 
^''•"""lar  till,,,  ,.„st,s 
iIkI 


'«  alKloiiici, 
''('  /ir.st  t,,„  ,1 


\vas 


'I*'  i-'i'.  Ii.'-i2, 
'i'lie  c'd-(. 


a  li 


••'  oiiiittwl  (on  ac 
l-iiii  to  tlie  17tli. 

''lie  anioniit  of 
'"'"»ii   in  color    ' 


ff'e  'listend: 

"' '^'"' ^■lil.■^;::;'':'•::''r'.''■' -"i 


led. 


'i^'oiint  of  (I 


"'  <''>iidition  of  tl 


!:''■•""   ''=i"'N  iMit  a 


iiriiic 
peci/i 


}^"'"'--  .leliris  and  ,„anv  t„I 
llie  iirinogavoall 


lan^rcd  from  80() 
K''avity  alH.iit   1 020 


"■  '"•'•H')  fro,,,  ,1; 


liev 


10 


t<»  1200 


cc, 


It 


and 


was  reddi.sli 


»  "ii'  miiiierotis  exam 


"'  "«iial  react 


''  ::''^^'^'  '"'t  "o  re,l  |,|o,„, 


't>"-^  'or  l)Iood.,,,l 


'•""t"'"<'d   i,„„.|, 
^'oi'l'll^clc- 


110  I'cd-hlood 


••'Jnxi.sclos  wcr 


"'"t'<'>'8  i.iado  between  tl 


•''"'g  matter,  l,„t 


I       ,  "fi.-iuius  wore  SPPH       u     .1  

;'!'''f '  7'  -s  vellow  W.  ri..'^^  ^''^  ^'^^''-  t' 
'ainod  only  a  trace  of  alb 


'^'  "'''■•'iid  tliel7tl, 


"••»vn  in  color,  no  | 


'H'  urine  bad 


iiiiiiii 


t'H'  c,.|„r  H'as  normal 


'<>",i?er  turbid,  and 


' ,  "'  ""  '^'"'"^  «"^'  no  tub 


='"•""""•     Tl,c  hatbs 

'Henty-.si.xbei;Metlie 
I'apidly,  with  tl 


and  til 


were  resumed  at 


"•'•«  Nvas  only  a  fi.int  t 


teniperatiire  fell  below  102. 


't;  exception  of  a  rei 


""  '•"'"'  examination,  mad, 
>lioued  no  malarial 


le  re 


OIVi 


'ganisms.     On 


'peatedly 


'>'"iiin  bnt  ther. 


noon 
low 
Icseiiee 
y  dun 
''^ejiteml 


'^"^''t^  l"(b,and  I 


U 


con- 
•e  cast.s.     ()„ 

race  of 
'le  took 


<'  convalesced 


•^^' «ve  days  <luratio„. 
"g  f'>o  first  few  davs 


^K'r  .9tl,  the 


■«  Here  no  tube 


cast." 


urine  still 


I'l'osi'iited  a  trace  of  all 
Cutaneous  System. 
Hieresa  H.,  asred  'M  /w«        *t 


t  I 


li 


312 


William  Osier, 


(6).  General  Erythema. 

Heinrich  VV.,  aged  12  (Hosp.  No.  8369),  before  taking  baths 
had  a  diffuse  erythema  on  chest  and  abdomen,  which  persisted  t'nr 
two  days. 

Charles  S.,  aged  18  (Hos}).  No.  10617),  had,  on  admission,  a 
general  erythematous  blush  upon  the  trunk  ;  no  rose  spots. 

(c).   Boils. 

During  the  4th  year,  throughout  the  autumn  of  1892,  there  ww 
many  examples  of  boils  during  convalescence.  At  one  time  there 
were  seven  or  eight  cases  in  Ward  F. 

During  the  5th  year  there  were  very  few  cases.  One  pationt, 
Evans  (Hosp.  No.  8029),  with  a  very  mild  attack,  had,  late  in  con- 
valescence, a  large  boil  in  each  axilla. 

Chas.  B.,  aged  17  (Hosp.  No.  10563).  The  attack  was  severe, 
with  high  fever  and  delirium  ;  twenty-six  baths.  Crops  of  boils 
began  to  appear  before  the  fever  had  fiillen  ;  there  were  many  small 
ones  on  back.  I^ater,  a  large  boil  developed  on  outer  aspect  of  ritflit 
thigh  ;  cultures  showed  a  pure  growth  of  staphylococcus  aureus. 

((i).   Urticaria. 

Theodore  B.  (Hosj).  No.  10298),  during  convalescence  had  an  ex- 
tensive outbreak  of  urticaria  on  both  forearms,  unassociated  with  any 
error  in  diet. 

(e).   Post-Typhoid  Abscfjss. 

William  P.,  aged  22  (Hosp.  No.  8145),  admitted  September  lltli, 
1893,  on  ihe  8th  day  of  the  fever.  The  temi)erature  ranged  from 
102°  to  104°,  and  fell  to  normal  on  the  25th.  On  the  'ioth  an 
abscess  was  opened  between  the  buttocks  and  a  considerable  anioiinl 
of  pus  escaped.  Cover  slips  showed  a  coccus  as  the  preddiiiiiiatiii!: 
organism,  but  in  culture  both  the  colon  bacillus  and  the  staphylo- 
coccus albus  were  isolat'^d. 

Olaf  J.,  aged  24  (Hosp.  No.  7992),  admitted  on  the  4th  day  of  the 
fever.  The  attack  was  very  severe,  and  the  baths  had  very  little 
influence  on  the  fever.    On  the  15th  day  he  had  a  slight  lueiuorrhage 


*"''^'"'""->'''-»''""''-..v.:^^^^^^ 


18 

IK 
IK 


/i'om  the  bowels      The  t  ' 

f"  ^'-  «fxth  week  a  hr^^Z!^"'" r"""^  ""  ^''^  ^^'^^  ^'ay. 

'-I'-atnre  did  „ot  ..i.se  ,l„nng  t  f,  ,  V/' '  '"'"'«'•">  ^-^-  TJ,e 
^''l''^  "-'  tl,e  p„s  showed  onlv  '  ;^""^^  f'^'—  Cove, 
eoccus  all.M.s  and  s.  aureus,  an.l  iuso  '   '"  '"^""■^'  ^''^'  ^^aphylo- 

«!'^V'n  the  7th  day  oniL  fcX;     •:p,':f  ^'  -''-«-'  0.,ol„„.  9,,,, 

-  -;i  -veiling  was  notieed  in    ^:       I  ^:;:  ^^^  "  --"  --ea  of  ..,- 
'    ='  well-n,a,-ked  .-ose-spot ;  hv  tl^  ;   ^  ^  "^'""'  -i-^  ='*  the  site 

"'■'"''!'""•    '^  -all  ai.e..  .  •..  .,,  J       ^  ■;;'  1-7-1  and  there  was 

^'"'"•''''=''--^--'' -'the  staph  vio;:::^:::;f^'-«^''-  ^'"'t-vs 

''■"■'■■"'^I^ao.edoWiro.p.Xo   r,j.,,,       ,    '.       ^• 
""  ^''*'  ^^1'  (•)  'lay  of  the  fever       "n     /^'  "        ""''  ^^^''^'■<'''  -^'"'-  '.S!.4 
^'-  22nd  day.     The  note  on  "mJ.  !      :rr^';-  '-''- nonna,  ..; 
-vera]  days  the  toes  in  th.  ri.ht   to,       ;     ,  1 '      "  '''"^"^  =     "  ^o'" 
■io..nm  there  is  a  well-n.arked  l.lnsh   ■  i      /•  ?  '?""'"''  ^'^^  -'  the 

-^■•"    <>''*'-HHwhehlnshpe^;t      ';?;■'■"''  ''^'^^'-^ 
i>e  toes  were  very  ten.Ier.     There  w  '  '''""'="•  ■^'"•'a'-os  of 

Tl.e  Ml  foot  was  not  affeetec      w;     j;);^'  '^f "-  -  the  dorsnn, 
-the  nsnal  'tender  toes'  whieh    <  o   e^      n  ''V'"'^  ^''-ondition 
0th  d,e  swelling  had  extended,  and  t  ,      "  ''"  '"^'"^     ^->"  the 

^'-f  t.>  the  ankle  Joint,  h„t  Z,,  ^  '":  "':^  '^"'^'^^  '•cached 
-'; :  .-f  the  dorsnn..  The  toes  a  J  '•  i!  I"^""'  --•  "-  -tire 
^»<'  '"^  -as  greater  and  fh.etnatll  !        '  ":'''^'^'-     '^>-  tlu"  KUh  the 


^uelliMg  was  greater  and  fh.ctnaHin,  »  "  "'";""''•     '^>'  *'' 
'■«'^'''-l  -H.rmal  on  this  ,U        T    \  ""'  ^'^"'^'"t-     The  te 


-acl..l  normal  on  this  day.  T  ,  '"''"'^-  ''''^  ten.peratnre 
;^^-  — '•  The  cnlLres  1; '::;r^  '''--'  -"'  ahont  ;  ij 
iomrus  aureus.     About  the  13th       '  •';''"'^''''  "^'  ^''^•'  -^taplu- 

nght  car  an.,  tenderness  over  tlfeLX"  ''  ''''''  ''^'''  ■"  ^''« 
-s  a  waten-  diseha.^e  f^.o,„  „e  "  u  d  ZH  '"'  '"  ^ ' ^''  ^'-- 
' '-  'over  did  not  rise  again  after  ul;  ^u  '"  '"''^'''  '-»^J- 

rilOlrina   T"       1    r.^ 


Tliomns  T,  age,i  30  (H,„p.  ^  '     ' 

I     ;;»""■;""'  "»J'.  «■"-  than',,™  /el  'a'i '  ,  '  ''T"'  ""■"-l-eenee. 


I 


William  Osier. 
^.^     1    ^  n«  thoueh  it  was  an  acute  periostitis,  goinc 

and  he  had  no  further  trouble. 

Nervous  System. 

r.  nP  T  EFT  Middle  Cerebral  Arteries. 
(a)    Thrombosis  of  LiEir  ivn^i 

See  Case  XXXIII  of  the  series  of  fatal  cases. 

(6).   Insanity.  ^^^^^^.^^^^  q^^^^,,,  i,,„, 

Florence  M.,  aged  22  (H osp.  ^  ,^^.     ^^,„,  ,,,,, 

1893 ;  she  had  no  initial  dehruun.      The  f'^^'^'^  '        ^^^^^, 

haths'did  not  n^tU^once  ^^^^  fever^-,  .^^^^^  |^^,^  ^^ 

of  abdominal  d.stensmn.     The  ^'-^^^     '^'^  ^         ^  have  vavi..u. 

November  14th.-'' Three  days  ago  the  pa     "be^  ^^^^^^  ^^^^^^ 

delusions;  as  that  she  had  l-j    -^,^\^^  ^j,  ,,,  throat.    8h. 
visitors;   and  that  another  pat  ent    v.sh  d  '^  ,q^^^__. ^\,, 

,i„gs  and  talks  to  herself  w  en   d   ^       ^-- ^  ^,^^^^^^^,  ,,^,,,, 
is  not  in  Ihe  least  melancholic,  but '«  ^  ^^^[^  Subsequentlv  s!,o 

She  thinks  now  that  she  .s  ^^^^^^J^^  ,,,,  lu.-  h.K, 
became  somewhat  melanchohc.     bhe     e  e  /,^^^^ „,,„,,„ 

which  seemed  to  improve  her  mental  -o"^.  on      ^_^      . 
;Ltter  and  left  the  Hospital  well,  January  7th,  1894. 

(c).   Catelepsy.  ^j^^  2^^^  ,,      f 

Betty  G.,  aged  27  (Hosp.  No.  ^^  «  '  ^dm    e  ^^  ^^_^     ^^^^ 

,,e  illness.     The  fever  h.  a  week  r.ged^^^^^^^^  ,,,,^^  ^,^^^. 

,,,.  tremulous,  no.y  and  w^  ^^^  f^;;^^^,!,,,,  ,,t  lay  withtl. 
.,fter  her  adnuss.on,  she  won  d  not  ^"^^^J'  ^  ,,^„,,,^i,,„i  ;„ 

:;:^r;::ru:d:'>uiL-^ 


Special  Features,  .Symptoms  and  Compl{catiom.  31  - 

30th,  she  had  no  fit.     Ou  this  d-,v   ..fv      .1 

('•).   PlySTERFA. 

(./■).  The  Pai.vful  Back  of  Typhoid  Fever  fTvp„„,„  « 

••I'aracteristic  cases.  '  ^"''  ''"'l'"'''^''  several 

^el!:^  and'^ri,;:  ;;^'!::;,—  --  ^^^ '---'  !-'-<«.,  the 

^  _^  l^__ .  ^^^  n>  wh.d.  the  .sym,,to.„.s  were  n.ilder  and  less 

^f;"^-'  aged  al)«nt  3.5,  admitted  Febniarv  19fh  ixo^  rr  .  , 
boon  in  War<l  F,  fVom  xXoveniber  14  1  n  n  '  ,  '  "'  '''^^ 
'^•I'l-oicl  fever,  a  ver,  typical  aU  .  H. tf:!'"'""  ^'^"''  ^^'^ 
less  and   nervous    and  'l  ec.n,.  .   .  '  ''o^vever,  very  rest- 

patient  was  (h'sehar^red   he  comnl.iJnnl    r        ""'^'^"^<^"-     i^e^ore  the 
"'»'-">  "I   toiiipiainec    of  soreness  in  fl.«  i      i       i 

stooping  and  in  walking,,  and  Lv  this  the  P ^    I  "'''" 

plied.     He  snvs  H.nf  fl  •  ''"1"''''"  ^'^"^^0'  \vas  an- 

>an  jiani  or  a  null  aohintr  character      Tl>n  „„      ■     ^- 
«e  uas  given  the  tincture  of  nux  vomica  in  large  dose.s, 


316 


William  Oder. 


and  the  Paquclin  was  applied  lightly  on  the  lower  dorsal  region  m, 
several  oeeasions  with  much  benefit.  Me  improved  very  slowly,  an.i 
left  the  Hospital  nearly  well. 

The  following  oases  are  of  interest  as  illustrating  milder  forms  of 
this  trouble,  and  in  one  the  pain  began  and  was  for  some  time  local- 
ized in  the  neck. 

Florence  M.  (Hosp.  No.  8448),  whose  case  is  given  under  the  sec- 
tions of  insanity  and  post-typhoid  elevations,  on  Decend)er  16th,  after 
she  had  been  sitting  up  for  nearly  a  week,  began  to  complain  of  severe 
pain  in  the  back,  which  was  much  increased  l)y  any  sudden  jar  or  after 
walking  about.  The  examination  was  negative,  and  there  was  no  iKiiii 
on  prciSure.  On  the  17th  and  18th  the  pain  was  too  severe  to  allow 
her  to  sit  up.  It  continued  to  trouble  her  for  more  man  a  week. 
There  was  no  disturbance  of  sensation  or  of  motion  in  the  legs.  ( )i) 
the  27th  she  sat  up,  and  after  this  she  improved  rapidly  ;  and  when 
she  went  out— January  7th— the  tenderness  in  the  back  had  almost 
disap})eared. 

Christopher  T.,  aged  32  (Med.  No.  3228),  had  sat  up  on  Octol.er 
4th,  when  convalescent  from  a  relapse.  On  October  6th  he  began  te 
complain  of  pain  in  the  back  of  the  neck,  particularly  in  the  tipper 
part.  There  was  no  swelling.  The  soreness  persisted  and  was  very 
troublesome ;  the  patidit  could  not  turn  his  head  from  side  to  >i.ie. 
The  Paquelin  cautery  gave  him  nuich  relief.  Nothing  could  l)e  felt 
on  examining  the  cerVical  vertebrte  from  the  pharynx.  Subsecpteiitly 
the  soreness  extended  to  the  back  and  down  the  hips.  He  hel<l  him- 
self very  erect  and  walked  stiffly.  He  said  that  he  was  more  comfort- 
able while  up  and  moving  about.  There  were  no  tender  point-,  ami 
the  movements  of  twisting  and  bending  were  not  painful.  The  tree 
application  of  the  Paquelin  gave  great  relief,  and  at  the  date  of  his 
discharge— October  21st— he  was  very  much  better. 

{g).   Painful  Lkgs. 

During  convalescence  patients  are  often  very  weak  and  --ro-joT' 
in  the  legs,  and  it  may  take  months  before  they  feel  well  and  strong 
in  walking.  In  protracted  cases,  when  the  patient  first  sits  tip  and 
begins  to  go  about,  there  may  be  in  addition  oedema  of  the  llrt  and 
legs.     Thus,  Thomas  T.  (whose  case  is  given  fully  in  the  article  on 


4       ^ 


dorsal  re<»;iun  ni 
very  slowly,  uik 


and  moved  al.,mt"jn^  ^^f  '"''"'""fe^ed  convalescence  aftp,.  I 
te--»l.     I"  0«   ,./  ,,,„  J;;"      >«  ™*.s  .1,0  cndi'ti.,,,  „  r„ 

"»i-  ".e  oaptio,,  „,,„,,  g;  j"«« "  ''^  i-t  ,„  .speak  „f  ,i,/„„„:,i;;;; 

»*1  for  .e„  day,  „,-  ,„„  ,,,^f;'«  ,   ^''=  »»;«.»«  and  «,iffi,e,;  p","' 
»«»„„(  for  it.  '^o"".  b-t  no  local  fea,„,.,^  devolopafL 

0(Ar  //. — Emma  E   ncrn,i  i  p  /tr 
'"  tlie  calf  of  the  nVhf  l„„         V       '  ^o^plained  a  m-eat  <Ip.,I    / 

"(1^189/^""/^^'",  '^^;'  '^'^  ^^  (H"sp.  .\o  9611  ^      ,    . 

'  ''  '^'  ^"^  «f  f'e  fii^t  week  of  fe;er     SI  l*"^'!'"'  ^^"' 

^evei.     She  had  had  from 


318 


William   Osier. 


the  outset  much  pain  m  the  left  leg,  particularly  in  front,  and  on 
motion.  It  was  also  tender  on  pressure,  but  there  was  no  swelli..- 
oi  redness.  The  baths  were  not  begun  until  the  'Jtli.  She  had  i.m.l, 
pain  in  tlie  leg.  none  in  the  popliteal  space,  but  entirely  in  front,  and 
.,n  the  ml.  she  complained  of  soreness  over  the  dorsum  of  the  fo.4. 
There  was  no  tenderness  of  the  toes  and  no  shooting  pains  or  mi.nh- 
ness.  She  had  the  tubs  regularly,  and  by  the  12th  the  pains  ha.l 
disai)peared. 

Ciuse  /F.— George  T.,  aged  29  (Hosp.  No.  8104),  admitted  on  tlio 
Hfteenth  day  of  a  severe  attack.  He  had  sixty-one  baths.  D.irin;^ 
the  first  week  of  convalescence  he  had  much  soreness  in  the  calt  ot 
the  left  Ice.  There  was  neither  redness  nor  swelling,  and  the  tcnd.r- 
ness  was  iu  the  muscle,  not  in  the  skin.  The  knee  jerks  were  slightly 
increased.  The  condition  persisted  for  a  week  or  ten  days,  aixl  at 
the  time  of  his  discharge-a  month  after  its  onset-he  still  felt  sore- 
ness in  the  muscles  of  the  left  calf. 

Case  r.-.Tohn  W.,  aged  26  (Hosp.  No.  9oG6),  sat  up  May  hi, 
1894  on  the  35th  day  of  a  very  severe  attack.  On  May  9th  the  .alt 
of  the  ri'dit  leg  was  found  to  be  swollen  and  tender,  chictiy  m  th. 
muscles.  "  He  had  been  complaining  for  a  few  days  of  soreness  m  the 
legs  He  had  also  slight  tenderness  on  pressure  in  the  left  calt.  He 
kept  about,  and  gradually  the  swelling  and  pain  disappeared.  There 
was  no  evidence  of  thrombosis  in  the  veins. 

Case  17.-Thomas  A.,  aged  42  (Hosp.  No. ),  admitted  Apnl 

2nd  1895.  The  fever  was  moderately  high,  and  he  had  forty-cioht 
bath^  On  April  15th,  before  the  temperature  was  normal,  he  l.cgaii 
to  complain  of  tenderness  of  the  toes,  chiefly  in  the  plantai  suriaces, 
but  slightly  also  on  the  dorsum  and  on  the  under  surface  of  the  heok 
Vfter  he  had  been  up  for  ten  days  he  began  to  complain  of  great  sore- 
ness in  the  legs.  There  was  no  oedema,  nor  any  redness  or  svvelling; 
on  standing  and  when  moving  the  muscles  felt  sore.  To  the  toueh 
the  skin  was  not  sensitive,  but  on  pressure  upon  the  calf  luusele.  he 
winced  at  once.  On  May  16th,  on  attempting  to  stand,  he  almost 
fell  •  any  effort  to  stand  caused  severe  pain  in  the  calves,  liiero  were 
marked  fibrillary  tremors  in  the  muscles  of  the  calf  of  the  n.^it  leg, 
He  was  ordered  to  bed  and  to  have  cold  applications,    t  or  ten  clays, 


witlioiit  any  loss  ill  lui, .     i 

There  was  no  ten.lernesrc^Tl/r.lIrvc,;.'''''  ''""^"^  '"'"''■'''""  ''^''-^'^^^^l- 

Tk.nder  Tofcs.* 

During  tlio  5t|.  vcar  there  wovo  .  .• 
..e.s  of  the  toes,^all  had  ha,  bat  h  "  "'"'^  ^^'■^'' ^^'•-"-'- 
<;-'•  fifty,  and  one  sixty-two.  ..  Ti^V^  ""''  ^^^^''^--Hve,  two 
'''«-e  than  usual,  and  extended  t  1.  ,"'  T''"""^  ^^'^  -<- 
-OS  .t  developed  before  the  tenl  t  re  l"  "  /'"-'  ''''■  ^"  ''-<^e 
■"«■  ^'-'  6th  year  there  were  only  t^^  1 ''"'''"''  ""•'"'^'-  !>'"- 
""■  '•■•^-al  eharaeters.  ^  *'"""  "'  ^»"'-  cases,  all  presenting 

Special  Senses. 

Otitis. 
iiarris  G..  ao-ed   91  nr         ^^ 

""«  »■"=  -^vori..    On  \„ve,„  W  ,4,,  ,1     "'■""'  ""=  S<»>"al  sv„,,,. 

"■"•  M  ear;  the  ,ua,„<,id  p,.„c  Jt  1'  :?;™r  ''''"'"^^ ''■"'■»4 

l»'.v  gland  on  this  side  wa»  ,   ,.  t         ""','™''"-    Tl,c  ,„b„,a,M. 

*"'«"««  »"''«'■*''-  and  gave  n„  fl,rll„.,;;,X'"  '"'"«'"""•     Tlie 

Theresa  H.,  a^ed  94  'w  -vt 
''^^^-  On  .^;ve.befli?l:^^;r^^^^^;1-«-'  ^^^«-"'-  ^'^1' 
-  a  discharge  f..,..  the  'i;ft",  ^n"'  "'  '"^  ''''••^'  ^-'^^  the.: 
l^l'0''ewas  not  much  pain;  the  dis ehn.  '"'  '•"'  '^''^^''^  tenderness. 
-''^■-  The  note  as  to^ndt  re  J  :t  ,"1,""?""'^  ^•"-  '^^  ^han  a 
GauliusF      f  '"^^  "^'■'''^'^J  «'Kl  not  a.Ided. 

Gaul  us  F.-(,.,en  under  post-typhoid  abseess. 
^liariesa,agedl7(Hosp.Xo  lOofi-^^ 

;  evere  attack ;  high  fever,  deliriun;  e'!    'o      ,"'  ^"^"■^*  '''''  ^^94. 
f^^'t  the  patient  had  an  offensive  it  ?"  "'^^  ^^''  '^  ^^'''^  "oticed 

''«*1  I'acI  from  infancy   but  Ttl  '"^''  ^'"'"  ^'"^'^  ^''>'-''-     This  he 

-■b-laysof  his  fever.'  '"""^  '""^^  ^^^^'^^vated  during  the 

*SeeVoLIV,p.69,ofthe^^<,.,, 


i 

I 

i 


U 


320 


William  Osier. 


Ambrose  B.,  aged  31  (IIosp.  No.  11310),  admitted  November  5tli, 
1894.  Severe  otitis  media,  with  purulent  discharge  during  the  heis,'iit 
of  the  fever.  Dr.  Bhuner  isolated  the  bacillus  pyocyaneus  and  tw.. 
other  undetermined  organisms. 

Locomotor  System. 

Arthritis. 

Frank  H.,  aged  16  (Hosp.  No.  11108),  admitted  October  lOtli, 
about  the  end  of  the  first  week.  He  had  in  all  twenty  baths,  and  by 
October  24th  the  temperature  was  normal.  It  was  a  very  typical  <usc 
of  moderate  severity.  On  the  26th  the  note  reads  as  follows:  "The 
temperature  was  normal  on  the  24th.  Yesterday  and  to-day  tluiv 
has  been  a  slight  rise— this  a.  m.  to  102.5°.  The  left  shoulder  is 
swollen,  red  and  painful,  particularly  at  the  very  top  of  the  juint. 
The  swelling  is  general."  In  the  evening  the  temperature  was  104. 1  . 
On  the  27th  the  swelling  and  redness  persisted,  and  the  boy  (duKl 
not  use  the  arm  at  all.  Hot  fermentations  had  been  applied,  which 
-■ave  a  good  deal  of  relief.  On  the  28th  the  condition  was  uncluuigcil, 
but  the  temperature  had  fallen  to  normal.  On  the  29th  a  striking 
change  had  taken  place,  altogether  within  the  twenty-four  hours;  tlif 
swelling  had  lessened,  the  pain  was  better,  but  there  was  still  rednes;^. 
The  swelling  subsequently  localized  just  at  the  top  of  the  acromion, 
but  it  gradually  subsided,  and  after  persisting  for  about  ten  days, 
disappeared  completely. 


Bv  W.1.LWM  OSLER,   „  o 

111  onlv  two  nf  tlw. 

l^^Case  XXA7I  the  ,>ati.u;a  f  s   " ^'ci  "^  """^'■"'  '>■  ^^''-i 
-^'y  "I  tl.e  clisea.0  by  a  dose  o      .s         7'?''  ^^'"■'•''  ^^'^-^  -Started 
-a"  ."tense «eptio.e,nia  with  ^L^::''     '"  ^J^  ^^'^^  the,. 
•ally  thKs  case  is  of  oxoeptional  i  UereTf  «  ,,  ' ■'  ■^'^''"•'^^''-    ^^'^-^- 

-ggosfve  of  oe,-ebro-.spi,,l  nu.  "  if"  ,  ''.Vr*'^^^^"''-^'«.v-Pton.s 
^''-'"..sclcs  of  the  ne<,k,  Wgiciity  ,  '  wT  'f"''^^  ^^'^''  '"'^'••''•ction  of 
7'  '■;"--"«  hvper...sthe:ia.     1   e  f 'r''"' '"~-' -Aex.s, 

;- '^'.-befbre  death  was  no,™a  T  j  J  1"  ""  '""'  ^"^  ^-• 
-Jl-f  our  attention  to  the  nossibi'itv  o^  ?  ^'""'"^  "^"^  P«''«titis 
^■'i^e  's  Mly  considered  by  D,  F  ^  ^  '^^'""'^  '"^^^tioi.  The 
fa.scicuh.s.  'y  ^'-  F^^-^"--  ,n  another  portion  of  the 

^  ASF  VV'vrr 

•C.n,i.„.,,r„„Vol.,V,f,|,eK,p.„,. 

■Io9 


460 


Wiltiaiii   Oder. 


TIh'  patient  luul  Imh'u  at  (Jarriscn,  Baltimore  county,  all  the  slim- 
mer in  a  nlare  where  two  l.oy«  and  three  girls  were  ill  with  typho,,! 
fever  Five  days  ago  his  illness  began  suddenly,  with  pain  iii  tli(> 
back  He  has  boon  in  bed  ever  since,  feeling  very  weak  and  liroii. 
He  lias  had  no  chills,  no  nose  bleeding.  He  took  castor-o.l,  and  han 
jmd  six  or  seven  watery  stools  each  day. 

On  admission  the  temperature  was  101°.     The  blood  cximinatio,, 

was  negative. 

The  p'ltient  was  a  well  formed,  well  nourished  man  ;  tlie  tnnxl 
was  clear;  the  tongue  was  coated  in  the  centre,  clean  at  the  ed^cs 
The  pulse  was  soft,  regular,  and  dicrotic.  The  abdomen  louk,.l 
natural,  was  nowhere  tender;  there  were  several  suspicious  look,,,. 
spots  on  the  skin.  The  heart  and  lungs  were  normal,  ihe  tem,„  ,,,- 
turo  range  in  the  first  week  was  from  K-,"  to  104.5°.  The  l,a,l,< 
acted  very  ,)romptlv.  He  had  three  or  fom  loose  stools  each  day. 
On  the  24th  he  was  a  little  husky  Irom  the  baths,  and  they  w.rr 

omitted.  . 

On  the  26th  and  27th  he  had  some  delirium.     I  he  pulse  wa^  II., 

dicrotic ;  the  tongue  was  swollen  and  dry. 

From  the  29th  to  November  2nd  he  seemed  somewhat  better.  I  lir 
spleen  was  readily  palpable;  there  were  no  fresh  rose-spots,  a.ui  tl,. 
abdomen  was  a  little  distended,  and  he  still  had  three  or  four  i.u>v.- 

ments  each  day. 

From  November  Jk'd  to  6th  he  l-  ^ame  worse ;  the  terapenituiv 
rose ;  the  diarrha>a  still  continued,  and  he  was  weaker. 

On  the  6th  the  temperature  rose  to  105.3°.  He  took  his  nounsl,- 
inent  well,  and  there  was  no  vomiting.  He  had  the  lead  and  opnm, 
pill  for  the  diarrh.ea,  and  hypodermics  of  a  twentieth  ..f  stry.hn,,,. 

Throughout  the  7th  he  was  extremely  feeble,  th..ugl.  latimuil, 
There  was  marked  fcrtal  heart  rhythm.  He  sank  gradually  ihiuugli 
the  day  and  died  at  5  p.  m.     No  autopsy. 

Case  XXVII.— i''^"eA'«  of  two  weeks  duration  before  a(lvus,voii ;  mod- 
'  erate  fever;  enlarged  >^pleen;  rigidity  of  muscles  of  neckaiul  of  right 
arm  ■  mental  dulncss  and  delirium;  cutaneous  hypera'sthem  aivl 
increase  of  the  reflexes;  s^nall  amount  of  albumin,  with  red  hloo<l 
corpuscles,  in  the  urine  ;  no  diazo-reaction ;  for  three  daij^  hejon 
death  normal  temperature  ;  parotitis. 
Susan  B.,  aged  18,  colored,  (Hos.  No.  9725). 


•'     '''''"'/>/    o/f/,.     /,„f^,f     ^,^^^,^_ 


lood  vxaminaliim 


he  pulso  wa>  1 1  j. 


H—Dkath    from    lNTEm,ruRE^.T,     Vp.p^ 

'''e  P"l.se,  and  death  o..cnn-e,l'i„  Tver     .t      •  '  ^"''  ''"■  '"■"'-•'•••P^'-- 
antopsy.  "^v^O  feu' niMHites.     Thon- was  „„ 

Cask  XXIII V 

i^'^zie  G,  aged  2],  (Ros.  No   784n     /         , 
'••""^'■•"■""■"^' of  weakness.  "  '"^^^^-'^"""^l  Augnst  1st,  189,3, 

Family  history  g„od. 

I'ee..  „,a..si„g.  ^''"^''  ''^  seven  months  old,  she  has 

On  ailmissiou  tl,e  ml™,  r    t         m  '®>'<"'«1- 

'*«"•■•'■  ■'&  It;:,::!,;!"  "■-  ^™«"  •^.-  ■•-i*  .„o  „ip. 


462 


Wll/lam   Onh: 


Hocoiul  Houiuls  were  well  licanl  at  tlie  hano,  the  Hwontl  aeociitiiat»'(|. 
The  temperature  <iii  adinisHion   wuh  low,  only    1<K)°,  and   for  tii( 
fir-tt    three    days    we    did     not    suspect    that    tlie    ease    was    one   nf 
typhoid   lever. 

Oil  tlie  1st,  2nd  aiul  .'{rd,  the  temperature  did  not  once  reaeh  lOli  . 
The  blood  examination  was  negative;  tliere  was  moderate  leueotv- 
tosis  (12,(100).  On  the  evninji;  of  the  .^rd  tlie  temperature  roseal..ivi 
103°,  and  she  eomplained  of  much  luadai'he.  The  face  was  Hii-hcil, 
tiie  toiijiue  coated  ;  the  spleen  could  not  l)e  felt. 

On  the   'Mh  a  number  of  jjerfectly  typical   rose  spots  wen'  stcn. 

The  temperature  had  risen  to  10/)°,  and  she  ha<l  iiad  baths.  Tliciv 
was  a  trace  of  albumin  in  the  urine,  and  a  very  distinct  diazo-ic:ir- 
tion.  There  wa.s  no  diarrlKca;  a  stool  on  the  otli  was  yellowi«li, 
semi-solid. 

On  the  6th  and  7th  her  condition  became  more  serious  and  tli( 
temperature  kept  lii<ih,  touching'  nii  several  occasions  10(5°.  The  piilsc, 
however,  was  of  fair  volume  and  between  112  and  120.  There  \v:i- 
no  diarriirea ;  the  spleen  was  not  liL'lt,  and  she  had  very  siicat  tension 
of  the  abdominal  walls. 

On  the  8th  she  seemed  to  suffer  so  severely  from  the  l)atli<,  ami 
remained  so  long  in  an  almost  collapsed  condition,  and  very  Mim', 
that  sponges  wore  substituted.  She  passed  about  fifty  segments  of 
a  tape-worm. 

On  the  nth  the  temperature  was  lower  than  it  had  been  for  Wm 
days,  and  for  nearly  twenty-four  hours,  to  8  a.  m.  on  the  Idtli,  it 
was  almost  continuously  below  102°,  and  she  seemed  better.  Slu 
had,  however,  to-day,  for  the  first  time,  diarrluea. 

On  the  10th  the  temperatnre  rose  again,  and  at  4  p.  m.  was  105"; 
the  diarrho'a  continued.  On  the  lOtli  she  was  sponged  at  7.:50,  and 
at  10.;30  p.  m.  At  the  evening  visit  nothing  special  was  iKiticpii 
about  her  condition.  Though  very  ill,  she  had  been  somewhat  Ixttor 
for  two  days. 

In  the  early  morning  of  the  11th,  on  going  to  the  Ijcdsidc,  tlif 
nurse  found  the  patient  gasping  for  breath,  with  an  almost  iiiipn- 
ceptible  pulse,  and  before  a  physician  eould  be  summontd  ^hc  wa- 
dead.  She  had  taken  her  nourishment  the  evening  before,  ami  luul 
not  made  any  special  complaint.     No  autopsy. 


^'   "^i'^dy  of  tl,,   Fafaf  Cosr.. 
'  "'/'""  Imnehilu. 


463 


Tlic  nlrly  l,ro„,.|,i|i,  „(■  ,,.„,,  ... 

Simon  S./ac-p-l  97    /lt 

'""•IVsagoho,,,,,,, 

«"  »  »Fee,  na,l  „■„„„  „,„„  ,  '  '"P  ""  an  ..,-,,cr  ,,o|,„„„„.  „ 

;«• '»..  .lay.  ago.     „,  I J  fc  ™:  'f  «'■. ,  "»  l.a.l  l,|„.,,i„^.    °"   " 

1  M»-     file  spleen  co„l,l  „„t  ,,,  f^,,^ 


464 


WiUiam  Osier, 


I   II 


Everywhere  over  the  chest  there  were  nu.nerous  coarse  r^les,  whee.- 
L  and  bubbling ;  no  tubular  breathing ;  no  dulness. 

The  Xt  tl  slight  diarrhoea;  the  temperature  remained  l.e- 

'^"o:  Tuth  li'Led  somewhat  better  and  the  baths  were  be,nn 
He^l     our  loose  movements  in  the  twenty-four  hour.^    He  rea.  d 

temperature  remained  high,  constantly  between  105    and  106  . 
took  his  nourishment  and  medicine  well. 

tlo„,  68  per  '^'^'^l^^^^T^^  ^ oy.«o^' "'« 

ounces.    He  Wame  miicli  wor»c  tluoiigl.        aay , 
rose  to  nearly  100.5°,  ami  he  died  at  3..M  p.  m. 

.                       ,1,      Unth  luno-s  were  bound  down  by  ol.l,  him 
reritoneu.  snjo^h^     c        In^.nuch  frothy  .,.n,n.  a„,l ta,; 

:^;;:::;,a.  s.!  °:Ln  a„<i  ,ede,..,.  <•  m.,  mn^s  ,vi.h„„t  »„ ., 

empn)sti.  ti.o  hroiu-hial    Inr.s  were  caseous. 

"^CrrXratotonro  «LL  was  20.  en..  aWve  the  v:,K,. 

ilie  nr&t  uictui  and  swollen  patck^ 

Fron,  this  potnt  'l"-™*  '^  , Ke  ,  alecrations  were  *,,» 
with  -M--hc..  "-.-^  J^-  *;;^,,^^  „f  ,,i,,y  ,,„„g,,.  „,,|,™„ 
ami  more  eraler-l.l.c  .■"■>"?»'  ^^j^„,i^<,  ^e^vale.!  «!«-! 

to  them.    Jnst  ahovc  the  valve  ''"^^  «""=;=  ^  ^  „,„,  ,„„„, 

.trating  the  ^^  ^^Z  i^  in  length,  .l,na,«l  HO 

ri:.iW  n^.*e  n  L  cLm  and  eoloo  the  solitary  folHeles ..» 
"Tal^edand  ulcerated.    The  mesenteric  glands  were  la„e,  .-*, 


^1  study  of  the  Fatal  Qms. 


IS  substituted.     The 
05°  and  106°.     lie 


465 

soft,  and  ha^morrhagic.     TJie  spleen  woi.^ho,]  '^m 
was  extensive  parencl.ynaatous  cle.ene  iion    "'^,^'™'"'^^^«-     'J^''^-'^" 
In    the   former  there  were  nnJ  "^  '"'"'"  '"^^^^   "<'"<^"ey,s. 

l.noaththecapsuIe4    ;L:r"ir'"f    ^^'.''^^  "^''■"^  visible 
ucre  caseous.  ^  ^P'^^^ata.    1  |,e  enlarged  gla,,,!,.  of  the  i.eok 


(c).    Endocanlitk  in  typhoid  fevn 


™i  -nda.^  inLtio.:::  :  r:  it;^^  T'rf ^'^'  ^  ^^'>'- 

tl'o  twenty-eight  post-,..orten.s  w   ih     ,        !  '"  '"'^f  ''''''■     ^" 
or  iiis  assistants  in  the  thirty-fort  ,  /""'"'  '•^'  ^'•-  ^^'^l^'' 

n>y  wards  i„  the  Johns  H,>nl   „    Ho!   f  .''"7  "^  '-'•''"■''  '■^'^•^■'-  «•«'" 
Xo  instance  was  present       d    «t^  t         '  "^'^'  "'^  '-^  ''"'^  '-n-ed. 

i"  ;.pi.oid  oases  'at  the  m!^:^ ;^:::::t:;!:r  f-' '  --"^ 

u'Hler  my  care  in   tlie  Philadelplua   Hosnit  .T         "  •         '  '"""'  ''"'' 
H-tm..t  to  place  on  record  here.  '^"■^l'"'*'-^'"!   '«  of  sutfident 

Tlie  extrejne  raritv  nf  tU^  i,  • 

'"r "-  only  eiJve,,  ii:;  :;!"'h  ::"t  '""'"'-^"t''  '"=''-« 

infaH.«,,  (hvoml  by  .1,0  i ',t,,,;,;,l  ,1  ''■""  "  '"■™<hn 

■f  ..mTncocni,  of  which  so  •     ,  '        "T'  "  '"'"'"■'  "''  "'«  «""'' 

t»li»™«.    I.,  rare  i«a,«l  ;  ,    "    '■'"■''' ''"""  '°""''  "'  ""■  vogc^ 

"<■  «""■■  "i.'* :     t:r  :t  ;.'",  "rr'  '^-  ""■  '»■■"- 

I»  .1-  /ir,s.  .as.,  horo  re„„r    d  .,    ',  fi  r     '      '"°"''  "'«'  ^''"'«"- 

-->..uhoo„,i„.a,:f.;,:t:::n-;-.:a^ 

'.=  taJ  .«,!  •  bee,,  i,      j  for  H        r'"'?'""    "'■"  f"""!-^  -i''  'l'»t 
for  .evo,-al  week".  '■'■°  ''''^''  '""  """  ''=  h^d  bee,,  ailing 


466 


William  Osier, 


II 


Condition  on  admission. — Tiic  patient  was  a  well  built,  muscular 
man,  was  unconscious,  could  not  bo  roused,  muttered  frcquontlv, 
and  liad  nnicli  tremor.  The  tongue  was  dry  and  cracked.  The 
abdomen  was  distended,  and  the  skin  presented  a  copious  rash  of 
rose  colored  spots.  The  sj)leen  could  iiot  bo  palpated,  owing  t,, 
the  abdominal  tympany.  The  patient  had  diarrhea.  A  UvUv 
apex  beat  could  bo  felt  in  fifth  interspace  in  the  nipple  line;  the 
area  of  transverse  dulness  was  increased.  There  was  a  loud  systoiir 
nnirmur  in  apex  region,  transniittcd  to  the  mid-axilla.  The  seooml 
})ulmonic  sound  was  accentuated.  The  pulso  was  117,  dicroiic; 
temperature  103°. 

December  14th. — The  patient  is  in  much  the  same  condition  ; 
marked  subsultus  tcndinum  ;  pulse  112;  temperature  102°. 

December  10th. — For  the  past  two  days  the  condition  has  Ixni 
very  serious,  though  the  temperature  is  not  high,  ranging  Iron: 
100.5°,  to  102°.  There  are  no  changes  in  the  cardiac  couditinn. 
During  the  afternoon  the  temperature  rose  rapidly  and  he  became  vcrv 
feeble.  The  thermometer  before  midnight  registered  109.6°.  lie 
died  early  on  the  morning  of  the  17th,  on  the  fourth  day  after  ad- 
mission. 

Autoi)sy. — The  ileum  showed  the  characteristic  lesions  oi"  typlioid 
lover.  The  Pcyor's  glands  were  greatly  swollen,  infiltrated,  and  a 
few  near  the  valve  presented  small  ulcers.  In  a  great  majority  the 
sloughs  wore  still  adherent.  In  the  cioeum  and  ascending  c(ih)n  the 
solitary  follicles  were  much  involved.  The  mesenteric  glands  were 
greatly  swollen  and  the  spleen  was  enlarged  and  soft. 

Heart. — The  jioiicardiuu)  was  slightly  adherent  over  the  riojit 
ventricle.  The  organ  was  considerably  hypertropliied,  particuhu'lv 
the  left  ventricle.  The  mitral  orifice  admitted  only  two  fiiiirers. 
Both  valve  segments  were  sclerotic;  the  chordic  tendinea?  wore  short 
and  thick,  particularly  those  of  the  posterior  valve.  At  the  base  of 
the  auricular  surface  of  this  segment,  and  extending  to  the  adjaccm 
wall  of  the  auricle,  there  was  a  Hat,  superficial  ulcer,  circular  in  out- 
line, nearly  2  cm.  in  diameter.  It  was  somewhat  raised,  had  a  grav- 
ish-yellow  appearance,  and  was  roughened  by  the  presence  of  a  few 
vegetations.  The  aortic  segments  were  healthy;  there  were  no  in- 
farcts in  spleen  or  kidneys. 


A  Study  of  the  Fatal  Cases. 


467 
Cask  XX VIJJ.-^,/„,^,,;,,,  .^  ^^^^^ 

Tl.o  patient  was  seen  at  her  ho.ne  bv  Dm         .    • 
«'y.^  l>.-0VK,u.sly.     SI.e  luKl  then  been  ill  fj '   ,    T      '""""  '^'^""^  t^'" 
acl.o,  loss  of  appetite,  and  o,„e,al      c   n!  n  '  '"■''^'  ^^''*''  ''««'- 

103.5°,  and  tbo  patient  lool^d  .m  l^'^^  '  !?  ^-'i-'ature  was 
and  brown.  Tbe  patient  was  jriven  •„  .  ■■  ■  '  *'"'^'"'^'  "'''^  '^''y 
-•'^1  -te..  tbe  Hospital  tba  ;^  "'i;^^^'-  ^^'l>'  -1  said  si. 
gettn^s  gradually  worse,  and  this  S  ^''' ''"V^"'" '" '•^^' ^'^  J'"'"^". 
i-norrhage  froL  the  b  ..^.^  .  ,, f^'"^"",  f '"   '^^^   to  bavo  . 

':' ^'"^  '-■  to  the  Hospital.   'sU^t^r^  '''  'r'^'  -"'  'bey 

s'o...  "'^'^  '''^'«l"'fe^  J>rofnsoly  on  a.bnis- 

Tlie  temperatn.-e  was  102°  at  6  „   n,  .  l    . 
i^ationt  bad  five  la.^e  stools  of  al  h.",;,  "'l""  Vl'  '  '*•  "'•  ^''^' 
was  dull  an.l  beavy,  and  did  .,  ,        ,'  "'''  '"'"'  ^''»ts.     8be 

^^'"^''>;''--i^M^.rL:;;o  wi^^^ 

-'  If  Pa'>lo,  tbe  sounds  wer    elear   b  t    't    i  "  T'  ^'''  ''"'^ 

was  shortened,  and  there  was  f.tal  I     ,;         V'*''"  "'"  '""^^  I''^"^^' 

'""'"'  "''^'"•^^'-  ''"t  there  ua.  s  il^  tt  •',"'•     '''"'  ^""'-"^■n 

i'ofelt.  "'^''*  ^^'"I'^-'-V  J  tl.o  spleen  eouhl  not 

The  following    mornin<r  the   ,v,t;,.,.t 
-l>-ture  had  n.>t  been  tb  oo°     ,  T,  rT"'"'"  '''''^'' ''   ''- 

98.(i°  in  the  axilla.     She  had  h  .d  ^     '  ''"'^  """'"'"fe^  '"t  was 

-"ta---d  bile,  and  there  was  a  ,h  ub  ful  d        '''"""■" '•'^'->'^'J'-v  ^-Jor, 
June  16th— Tbo  f-..  /       """"' ^''^^o-i'caetion. 

■"-"..•  Thep;;L;:r;t'-^xtrr'"T^^^-«'''^«^°^''i« 

f-J  -ly  a  blood-stained  n'ucus      Att"'  '"^  'r'''''  ""^^  •^'•^■' 
''o'"K  -ell;  the  pulse  was  of  lood   .  ''  '";  •''''  ■^^'^'""^  *"  '«" 

spoken  to.  ^  '■' '^""  •""•' '^tupid,  she  answered  when 

-^t  8  p.  m.  the  patient  was  delirious  -ind  I.,  i 
i'.V|.onostl,esia  of  the  skin  so  that  ''  '"-''^"''="'  <''«'"'^e 


I 


.    I 


468 


William  Oslei: 


and  feet  were  cold.  The  heart's  action  was  rapid,  feeble  and  tuniul- 
tuous.  The  temperature  had  risen  to  102°.  The  abdomen  was  not 
distended  and  the  liver  dnlness  was  not  obliterated.  At  8.15  p.  ni. 
the  patient  vomited  100  cc.  of  dark  brown  fluid,  which  reacted  ior 
blood-coloring  matter.     She  gradually  sank  and  died  at  8.40  p.  ni. 

Anatomical  Diagnosis. — Typhoid  fever ;  lesiom  in  the  small  and 
large  bowel;  ver/etative  endocarditis;  acute  splenic  tumor;  extenaive 
necrosis  in  liver. 

Body  was  well  nourished  ;  rigor  mortis  marked. 

The  lungs  were  dark  in  color,  hyperremic;  there  were  no  distinct 
areas  of  broncho-pneumonia.  The  bronchi  contained  much  Ihitliy 
mucus. 

The  pericardium  v/as  smooth,  and  there  was  no  excess  of  peri- 
cardial fluid. 

Heart. — The  left  ventricle  was  contracted  ;  the  right  disteiKlid 
with  dark  clots ;  the  organ  was  not  enlarged.  All  the  valves  wvw 
normal  except  the  mitral,  along  the  edges  of  which  there  were  a  iimu- 
ber  of  recent  vegetations  varying  in  size  from  the  head  of  a  pin  to  fnui' 
or  five  times  that  bulk.  Tiie  heart  muscle  was  dark  brownish-nd  in 
color,  slightly  mottled.  The  coronary  arteries  were  normal.  Tlie 
intima  of  tlie  aorta  was  smooth. 

The  spleen  weighed  1020  grammes,  was  soft,  of  a  deep  ochre  yel- 
low-brown in  coloi',  opaque  and  very  cloudy.  Scattered  throuiilioui 
the  substance  were  reddish-brown  specks  the  size  of  a  pin's  head  iiiul 
smaller,  with  liypei'ajmic  margins. 

The  kidneys  together  weighed  400  grammes,  soft  and  swollen,  tlie 
cortices  pale  and  grayish-yellow,  in  color;  the  stritc  were  almost 
absent. 

Intestines. — Beginning  in  the  lower  part  of  the  ileum  there  wore 
the  usual  typhoid  lesions.  Tiie  solitary  follicles  were  enoniioiisly 
swollen,  elevated  above  the  surface  as  much  us  4  mm.  The  swoiloii 
Peyer's  patches  had  firm  edges  which  slightly  overlapped  the  lw«e; 
some  of  these  had  undergone  necrosis,  beginning  on  the  surface;  aiul 
near  the  valve  were  a  number  of  patches  in  which  sloughing  had  oc- 
curred. In  the  ileum  about  a  foot  and  a  half  above  the  valve  there 
was  a  small  hsemorrhage  beneath  the  mucous  membrane,  projecting 
as  a  little  blood  cyst. 


^  study  of  the  Fatal  Ca,es. 


)  excess  (it 


Throughout  the  cntir,.c,„o„,„,, I     ,  '  '"^^ 

-l«  were  „„if„r„,|y  „ffe„,«l,  .„„  I'f  '"'f'""  ""■solitary  ,i,,. 
hr„e  ™»,.r„w-lk,  ,«„  ,,„„^„,  »'Hv  o„l,,rge,|,  „,„,  ,. ,/  , 

;ver,a„d  fro,,,  the  |,M„e,„.     ft^  nt  Mr  "'"  ^"'""■'  «■""    <1. 
h  reg,.e.al.,„c„l„,,i,,,,,/,,  ;"^.    «  later  ,„^„„,,  ,„  „„,,,. 

"'"" "°"'°' "''-''■''■-' -'';s';'rt;;r,;;:,j,r'--'- 

Convulsions  in  tvnlmiM  f 

MiMclnson  (TI.e  Continued  Fevers  of  P  n 

':«".  !>•  04i)  states  that  in  2960  cZ  ,        T    ^'''''''"'  '^^^'''-'l   Kdi- 
-•     Inoneof  thesetheoonv  ,^'::::"'--  '''''''''  '"  -' 
-    the  sixteenth  day,  and  the  padent         ,      '''"  '""^■''  ^^^''''Mnn 
afterwards.     The  kidneys  were  fin  J  •  '"'"''''"'^^  ^'^^^  «"  i'onr 

a  'oy  of  thirteen,  died  'uddeny:',.'^:  :/''--'•     ^  --'"'  - 
r  -^-'^  m>  post-n.orten.  examin    r     H  "  :'"  ^'"■'•''^'^''  "-• 
"V"lsu>n.s  oeenrred  on  the  eieve  t      ,av  *'""'  ^•«'^^'  ^-'--1 

t|'e  fourth  .nstance,  the  patient  reeov    e    i  "'''  '"''°^'^''-     I" 

'ons,  Jastn^g  a  quarter  of  an  hour  II  '  '''''''  ^'  ^'^ -onvuJ- 

f^-     The  fifth  ease,  a  n,an     ^d  't     ^  '  T'^'f  ""  »'-  fourteen  t. 
•lay  two  severe  epiJeptiforn.  cofv  d   on^C^^^^^^^  ""  '^-'  twelfth 

-,  a  „.n  omty,  during  conval     ^^e      dT"'"'i     '^^''^  '^^^^^ 
acLs     He  had  also  thrombosis  of  the  left  f         ?'  ^^''^^'Pf'^o'-'"  at- 
a  good  recovery.  "'^  '^'t  femoral  vein.     He  made 

Jii  Volume  XI  of  tl.«  T„ 

-  ".,„l,er  20th  i„  „„  ill„e,,!f  I  ',,   .       "  ,''^"""«  "■""  »<''-'« 
l«...o  .as  al«v.e  ,05-.    O,,   ,,e  2     f.rf  "  '"""""■    ™«  .»». 


Rl 


<  I'l 


470 


William  Oslei: 


the  third  attack  at  9  p.  m.  he  suddenly  expired.     No  clot  or  Jiny 
lesion  was  found  in  the  brain. 

Case  XXXIV. —  Very  mild  Ujphoid  fever  ;  development  nf  sccov 
convulsiom  on  the  ninth  day;  death  in  a  convnhion.  Tlirmn- 
hotiis  of  branches  of  the  left  middle  cerebral  artery, 

A.  B.,  ii<red  22,  (Hos.  No.  1261(5),  admitted  April  24tii,  LS!)"), 
complaining  of  headache,  pain  and  fever. 

When  a  child  he  had  acute  rheumatism;  no  other  serious  illness, 

On  the  21st  the  patient  felt  dizzy,  had  aches  and  pains  all  oyer  ilic 
body,  and  felt  ger.erally  miserable. 

On  the  22nd  the  headache  persisted,  and  the  next  day  hv  liiid 
bleeding  at  the  nose.  There  was  no  vomiting,  no  abdominal  imin, 
but  he  had  slight  pains  in  the  calves  of  the  leg.  For  a  few  days 
prior  to  the  onset,  the  bowels  had  been  constipated,  the  appetite  p.Kir, 
and  he  had  a  bad  taste  in  his  mouth. 

On  admission  at  10  p.  m.  on  the  24th  the  temperature  was  1()4  , 
but  sank  in  the  morning  to  100,7°. 

Patient  was  a  well-nourished,  healthy  man,  with  a  good  colur, 
The  tongue  was  furred  and  brown  over  the  dorsum.  The  exuniiiia- 
tion  of  the  heart  and  lungs  was  negative.  The  abdomen  was  not 
tender,  not  distended  ;  there  were  no  rose  spots  ;  no  diarrluea ;  the  Icii- 
cotiytes  were  5000  per  cm. 

On  the  25th  and  26th  the  temperature  remained  between  100°  iiiid 
102.;}°,  not  reaching  the  bathing  point. 

On  the  27th  the  temperature  only  once  reached  102".  Spots  \mv 
visible,  and  the  spleen  became  palpable. 

On  the  morning  of  the  28th  tiie  temperature  was  99.3°,  and  inse 
in  the  evening  to  100.1°,  and  he  seemed  doing  very  well.  Tlurewas 
no  diazo-reaction  in  the  urine;  there  was  no  albumin;  a  tiw  pus 
cells,  and  an  occasional  cast  were  seen. 

As  we  were  making  the  visit  in  the  ward  at  noon  of  the  2JHh,  Dr, 
Thayer  was  sent  for  and  found  him  in  some  distress,  and  feelinir  uneasy 
in  his  head.  The  pupils  were  dilated,  and  in  a  few  minutes  lie  liaii  a 
short,  sharp,  general,  clonic  convulsion,  beginning  almost  simultane- 
ously in  both  arras.  The  eyes  showed  marked  conjugate  deviation  to 
the  left  and  upwards,  the  head  also  being  drawn  somewhat  to  the  left. 
For  about  an  hour  the  convulsions  were  repeated  at  short  intervals. 


No  dot  or  !iii\ 


^»  '^'^"^/^  of  the  Fatal  Ca,e.. 


Ipril  24tli,  LSil.-), 


rature  was  104°. 


between  100^ 


02°.     Spots  wc'iv 


Morplua  was  ,Wven  hvpo,lormieam.         ,     m 

-ame  ]os.s  inton.se,  and  fi„allv       id     if      '"'''' '"'''"•     '^^^'^^  then 

/'"•'"^  ^'-  -"vnlsions  tlH...    V      "  ;"''f""-^'-  ^^  overall, 

fl'e  conv„lsio„,s  rocurml  uiH  '  ^'""''''^'-'""l  look-.     At  5  , 

tio.^s  of  c.hlor„f;>,.n,   (/"         '>'''^f  ^-•"'■'O^  and  i„  .spit;  ,/  ,        "• 

Akatomtcal  Duo^osis  -r,  ,   • .  -  "'  '  "■^'^• 

^'»rer  ileum;  thronbo.,s  of  L,:,,Jz7  i^'''''- '  -^"perficlal  ulcers  in  the 

'i'lie  iJeiiin  was  tlie  seat  of 
'■"^  f '«  iej.nu.n,   to  a  Jess  J J"';^f  ''«^7«''''l.agic  enteritis,  affe,,- 
;7"'--  -s  ,,vpor.nH-c,  a  d        „  ,'"'  !'"  ''-'-      ^i.e  ,„,.,:  . 
;  -  place  into  the  subst^n^    "^      -^--tions  of  blood  h 

at(  ,es.      1  Ley  were.. nperfioial  partlv.x.     t       ""''  '"  *''«  ^'oyer's 
f'-  largest  „.,t  n.ore  tba„  i.5  J^^T     J  '"'""'*''  ^'^  '-">- 
'"ejnbmno  wa.s  h.on.orrhagio.     'ri,     .      '  ''  •  "'  ''"^^^  '''  ^'-  '""oo,  s' 
=!'"'  -f'ened.     The  heart  valves  w  ""■^''''^"•'^'  g'«"<Is  were  enlarZ 

-  -i'-.sions,  n..ch  J^^^  anil  T''     '^''^  '""^«  -7? 
^'r'  «-:' flowed  free],  n-onrlh::'      '^'"'"'^^  ""  -^-n  bhj! 

iiiani — ihevv  was  an  .nv.,.    e  .i      " 

""«  Has  seen  to  involve  the  branches  ^'/''".^""'^  «f  the  autop.sy 
--';-!  artery;  '.ut  at  that  tin,e  t       ,   J^^^^^^  ^^«-  the  n.iddle 

'^"l-q„ently  in  the  forn,ab-n-i  anL   d  '  ""  '"^  ^"'"P'^tecJ. 

tl'ronibi  were  situated  in  tU.      ''*'"f"^''  S2,ecnnen  it  was  seen  thi^  fl 

■";;«*,,  „f  .„e  ™.,i::r,"  ;:l''"^'" "  '-■•--™ »- 

'lie  meninge.s  over th  "  "utiy.  i 

''-'"•ai"  substance  eorrelnd?;:!?";^^'"^^'  «'"«''  iuen.orrhages  and 


!    I 


u 


472 


William  Osier. 


the  immediate  neigliborluml  of  the  thrombosed  vessels.  Tiierc  anas 
..xtend  sometimes  for  a  distance  of  2  cm.  (usually  toward  the  convex- 
ity) from  the  vessels. 

The  internal  carotid  artery  was  free  from  thrombosis,  as  likowisr 
the  Sylvian  branch.  The  ascending  parietal  and  parieto-temporal 
arteries  including  at  the  points  of  their  origins  in  the  middle  cerehnil 
artery,  were  occluded  by  an  adherent,  i)artly  decolorized,  and  (iniie 
iirm  t'hrombis.  iSIore  recent  dark  thrombi  were  traceable  into  il„. 
branches  of  these  arteries;  for  example  into  the  branches  rnnnin-  in 
the  Rolandic  fissure,  the  sulcus  between  the  ascending  frontal  iryri 
and  the  ascending  frontal  convolutions,  and  the  branches  supplyini: 
the  tempero-pariotal  region  generally.  The  inferior  external  fr.Mit;il 
artery  and  the  arteries  of  the  anterior  perforated  si)aces  were  free 

from  thrombi. 

On  section  of  the  brain  there  were  no  gross  anatomical  lesions. 
The  ventricles  were  not  dilated. 

"The  cultures  from  the  spleen,  mesenteric  glands,  liver,  Uidiu-vs, 
both  lungs  and  heart  muscle,  showed  the  typhoid  bacillus.  I'ldin 
the  lungs°streptococci  were  obtained  ;  from  the  peritoneal  cavity  tli( 
bacterium  coli  commune.     Bile  and  bone  marrow  (ribs)  were  stcrilo," 

HI,— Accidents  of  the  liEsiox. 

(«).    Hcvmorrhage. 

In  the  fifth  and  sixth  years  there  were  twelve  cases  of  hemorrhage, 
making  in  all  twenty  cases  in  the  389.  Of  these  three  died  directly 
from  the  hemorrhage,  and  in  three  perforations  caused  death.  In 
this  series  the  following  is  the  only  case  in  which  was  directly  due  to 
the  bleeding. 

Case  XXXIII.— ^am("ss/o?t  in  the  second  week  of  a  severe  attack: 
profuse  and  repeated  hemorrhages  from  the  bowels ;  death  on  tk 
second  day  after  admission. 
Anatomical  Diagnosis.— Typhoid  ulcers  in  ileum ;  hemorrhagic 
infiltration  of  the  edges  of  the  ulcers. 

The  clinical  and  anatomical  details  are  given  in  Dr.  Bhun.r'-  paper. 

J).  340. 


Is.  Tliero  anas 
rard  the  coiucx- 

•osis,  as  likcwisi' 
parieto-tenipiiial 
;  middle  ceri'l)nil 
)ri/od,  and  (|uitf 
racoablo  into  the 
nclies  rnnniii'j.'  in 
lin<I  frontal  ijyri 
inclics  snpiilyiiii; 
external  frontal 
sjiaces  were  ti'tr 

latomical  loions. 

Is,  liver,  l<i(lncy«, 
[  baeillus.  Finni 
itoneal  cavity  tin 
ibs)  were  sterile." 

N. 


368  of  heniorrlnigo. 
three  died  direotly 
L-ansed  death.  In 
vas  direotly  due  to 

f  a  aevcvc  attack; 
ywels ;  death  on  tk 

!uni ;  liaMuorrliagic 
)r.  BlnnierV  pa|)er, 


^1   'Sfndi,  0/  the  luual  r '„.,,. 
{1^)    I'erj-nralion. 


473 


Of  the  twelve  i\vinU<  ;,.  fi      ,.,., 

•^'  r  ''''''  ^^*^'-*'  <'"e  to  perforation      Tl         '"  '''''  ""■'•^^^^".  '•  "• 

;-— ^l-"  in  the  series  L'  .^o^    ^  is     "  ''TT-'  •"•'""^''^  ^'-" 

;f  •;•  ^''-  Hu.t  whi,.h  o,v„rred  Vlu^^^^  "  "^ '^  -'^  ^  ^Wu.tion 

ttlele«s  than  the  poree„.,g„i„   I  a'  '::!' ^  '-«<> '-'..-S  and  is  a 

H..p,tal.     Thepereenta,.'.f  p,,      ,    ,:,      '-^  '--  ^'^  the  Ji..ishane 

Case  XX J V a,i    •    •  •  >. 

'm.  CO.,,,,.,-,,,,,?.  .„■-:■,,':„:'";,:;  "^,'  """■"«'  ■^'■'"™"-  -^.h, 

""    na.„l  ,,ev„„,  „„,„  „J^^  2  '     ","     '■^■'"'""1  '•■™-  ". 

i»-"-»i:i-"t';  t.»  1,0;:, !:  z;::f r^'-;''''' ''-i-'-  -a 

T^l'e  l.atient  Nvas  a  health v  Inn        '        . '''''  ^^^heteri^ed.  ^ 

••^'^'  ^'-^''ed;  the  io:^e\^:'^jf^^r''^^^rU  thefaeea 

"^•eryulK-re  soft;  there  were  no  m  '     ^''"  '''Women  was 

f^-  '^''---ination  \  :Ir,T^i '"  •^^'^'^"  -« -^t  ! 

^'"Perature  range  was  not  idgl  "f  i"      "?  ""  "^^^^^^^^     The    . 
«o«i;'tal  she  had  only  si^  Ss  '°t,  /?  *''^  ^'''  '^^'^  clays  in 
^^'«^-  ;;>-  on  the  eiglh  she  h^  ftl  !Zt'  '''''''  ''-'  --^- 


I    ;  HI 


U' 


474 


]Vi//i(im  Oa/n: 


On  .Septt'inlHT  9tii  and  lOtli  tliD  tomixTatiiic  was  liiijlicr  iiiul  iiini;' 
porsistcnt.  T\w  |)iiiw  was  ri'ifuliir,  of  t^ood  vdIiiiiiu,  and  not  (licmiic. 
Tilt'  alidoniiMi  was  not  distended  ;  tlie  spleen  was  not  palpalile,  Mini 
tlit'ic  were  no  rose-s|)ots  to  1k!  seen.  She  had  two  or  three  soft  move- 
ments each  day. 

On  the  1  nil  iind  i2tli  the  teniperatii"e  Uopt  between  10"5°  and  104°. 
The  alnlonien  was  soft,  not  distended,  not  painful  ;  the  ton^riK  wms 
fnrred,  not  dry. 

(^n  the  null  she  was  not  so  well ;  pnL-e  was  more  rapid,  and  remind 
130;  the  temperature  was  nearly  10.")°.  She  eonipiained  of  i>;iiii  in 
the  abdomen,  liiit  there  was  no  special  swelling-.  She  had  three  move- 
ments on  the  l;5tli. 

On  the  llth  the  temperature  was  almosi  'onstantly  al)ove  Kit  , 
and  at  2  a.  m.  reached  105.2°.  The  abdomen  was  slifiluly  disieiiilcd  ; 
the  (liarrlKca  had  increased  very  miieh  ;  the  respirations  were  >lioit 
and  costal.  The  hands  and  feet  were  cold  and  clammy.  The  trniv- 
itv  of  the  general  condition  coiitrasle«.  with  the  comparatively  slio;lit 
local  features.  The  abdomen  was  not  much  distended,  and  pai  ilui 
only  on  deep  pressure.     There  was  f(Etal  heart  rhythm. 

Throiiiihont  the  iiitrht  of  tiie  14tli  she  liecanie  much  worse;  the 
moveiiK'nts  were  frequent,  and  the  condition  of  collapse  was  marked. 
She  was  given  sulxiutaneous  injections  ol  salt  solution.  The  pulse 
was  verv  rapid,  almost  unconntabie.  The  patient  took  her  iiniiii-.h. 
ment  well.  The  abdomen  became  more  distended,  tyiniiaiiitic  ami 
tendt'r.  There  was  3  em.  of  liver  dulness  in  the  right  nipple  line. 
The  patient  became  much  worse  throughout  the  <lay,  and  died  at  2 
p.  m.  in  the  afternoon  of  the  tenth  day  after  her  admission  to  Ims- 
pital,  and  about  the  twenty-first  day  of  the  disease. 

Anatomical  Diagnosis. —  Ti/jtiioifl  fn^pv ;  .vcelliu;/  and  mvnm 
of  lipnith  foUkk'H  in  .wuill  and  larf/e  intent i ncs ;  </re<d  siirlliii;/  nj 
mucosa  of  appendix  with  jierfundion  ;  lU/fusr  jHritonitiH  ;  f/eiirnil  in- 
feotion  with  Ike  tt/phoid  badllas. 

Peritoneum. — The  intestines  were  matted  together  by  fresh  lilinim 
purulent  exudate,  most  abundant  in  the  right  iliac  region.  SeiiuMif 
the  coils  of  small  intestine  hail  a  <lried  glazed  appearance,  l)iit  were 
intensely'  congested.  On  separating  the  ileum  from  the  c ioeiiiii,  to 
which  it  was  adherent  by  fresh  adhesions,  an  enlarged  and  swollen 


'V/«r/y  nf  Ihv    Fai„i   r,,,,,^ 


af)|)('ii(H.v  was  socn    •,.. .  •        1 

^'''''Hcs  K,  a^re,|  26  (Flos    V,.    lo^o-,      ,    . 

He  lias  nevor  been  ill  ,in(il  tlw,  . 

---     He  i,a.  i.pt  al.::  :.'',;:  "^  '-'<,  '.-lad.  a„. 
f"  ''■■'^  "ot  l.a,l  any  |>l„,,|i       „    ^j.^';  '^^  ^''   ''■  "l>  work  .six  dav.s  ago 

::::;;:.'-'- ----"-:;  t':::;i 

-.l,,ro  ,e„,le,,    Tl.ore  „  V    l'  '  ■'■'"""'■•""'I.  -«,  tv,„,,„„i,i 

'f  '^  l>-  "1.  to  104  0°      Ti         •  a''-'>iissioij  was  101°  .,n,i  ,. 

*■"— wt'^.-k';;: "'"""  '■'""^"■■«'  ° '--  %»i".e «:;:',';;:: 

Diiniiir  the  first  week  in   H      v  i     . 
^tamly  between  103°  and  moZt'^T'^'^'T'  '""^-^  -- 
''''-■"  ^^«-^  readily  palpable  •  tl  e  ton  ''''^'  f'''''"''^^'^-     The 

"•as  no  diarrhcea.     Thi  „,t':.t  r  T^''"  '""'  ^''"-^^  '""'^  '"'^^vn  •  there 

^^  ;•  '■■•/'«  '-^'  a  pX  i:,:i.::;:  ^^^ji/'-f  ^e  21st, ;,.:!;:: 

"""'  ^'""^'•'-    Ti.e  h.nu.rrhage  did^  T    ,  J  :,    ^^  -«  "right  red 

uuencettie  temperature.    He 


i  i 


476 


Wif/!nrn   Osffr, 


was  ordoml  the  lend  mid  (»|)iiiiu  pill,  iiiid  on  tlu!  22nd  lio  had  tliivc 
irivolimtarv  niovcruciits,  noiu'  of  uliicli  coiitaiiu'd  l)l()(»d. 

On  the  22n(l  and  2;}i'd  he  sccnipd  lurtcr  ;  tlw  tcnipfraturt'  wns  nnf 
so  liifjli,  l)ut  he  still  had  slijj;lit  dii'.irhd'a. 

On  the  cvf'ninj:;  of  tiic  2ltli  tlu'  patient  eoinplainetl  of  scvric 
ahdoniinal  pain  ;  he  became  nineh  oxeiteil,  attenijitcd  to  ^rot  out  of 
bed,  and  reliis(<l  to  allow  the  nurse  to  spmifie  him. 

On  the  morninji:  of  the  25111  the  ainlonien  was  not  distended,  wii' 
symmetrical ;  there  was  marked  jfeneral  tenseness  of  the  miixlcs 
and  tenderness,  most  sevctre  in  the  hypogastric  rejjion  and  to  the 
right.  On  percussion  it  was  tympanitic;  the  tympany  extended  as 
hij^h  us  the  lower  border  of  tlu*  sixth  rib  in  the  mannnillary  line. 
The  hepatic  flatness  was  obtained  on  the  sixth  rib.  In  the  mid- 
axiliary  line  the  tym|»any  extended  as  Wi^h  as  the  seventh  lili. 
On  auscultatory  pereussion  the  note  was  (everywhere  carried  di" 
tinctly  to  the  ear. 

The  patient  was  very  much  excited  throughout  the  day,  and  talked 
irrationally.  In  the  evenint-;  the  temperature  wa.s  104.3°,  and  lie 
became  quieter.  He  was  sweating  profusely,  and  the  extremities  wire 
cold.     He  sank  and  died  early  on  the  morning  of  the  2(jth. 

Anatomical  Diagnosis. —  Tjnihoid  itlceration  in  ileum;  pcrffuri- 
tion ;  f/ciieral  jnrito)iitifi ;  jtarinc/iipiKi'  lUS  i}c(/e)ierafin)i  of  liirr  (dkI 
kidiu'i/n. 

Gas  escaped  on  opening  the  peritoneal  cavity.  About  l,()l»)  cc,  of 
turbid  fluid  mixed  with  fa'ces  were  in  the  pelvis.  In  a  loop  of  the 
small  intestine  which  lies  deep  in  the  pelvis  there  were  two  pt  it'oiii- 
tions  within  2  cm.  of  each  other.  The  Peyer's  pat<!hes  in  the  npppr 
part  of  the  bowel  were  only  slightly  swollen.  Beginning  about  a 
metre  above  the  valve  the  patches  showed  areas  of  superficial  necrosis, 
and  lower  down  there  were  shallow  ulcers.  About  50  cm.  ai)ov('  tlif 
valve  there  was  extensive  nh'eration.  One  ulcer,  measuring  ."5  by  ].■') 
cm.,  witli  a  base  to  which  the  sloughs  were  still  adherent,  showed  a 
perforation  the  size  of  a  pin's  iiead ;  2  cm.  below  this  was  another 
ulcer  with  a  larger  {lerforation.  The  mucous  membrane  just  about 
th  valve  was  irregularly  ulcerated.  The  vermiform  appendix  was 
not  ulcerated.     There   sere  only  two  shallow  ulcers  in  the  <!eciiiii. 


^   '"^f"'.'/  0/  ,l,r   F,„„,   ^,,^^.^ 


CO, 


The  sj)I(.,.|i  \v,.|,,l,„,i  A7n  ^^^ 

■'■"!"f-'v"' •  "'nl''  .rr:;:;.  '''■  '■• ' <" 

'";/;' t'':i '"'  ''?"'"'■' '•'  ""»k- '''■  '"'""■""'  ■'"'•'■  '""•■  >«h 

iie  nas  always  been  a  )i,..,|f|,„ 

'"■•■"  •''•'<  <""•  four  ,Iavs  bof;  ,■  •  '        '""'  ''''^"  f''"t  lu"  ind    ' 

Oil  iidinissioii  (|j(.  ,,,,,,, 

J     .    ""         •    "  was  not  palpable      Tl                      "''''^'  "atiiral  • 
'»■  »«".e,l  ,l„i„,.  „i„.,,. ;  """'Ri'  »1  t.nie,  ,.«,|«,  ,  , ,^|. ™  • 

^"'■piiIsiMvas  119    ;  ■         '         ^  "'1^   Qiiietor   l,.,f 

"' ,"";  i»>'™'  wi,, j„  ,s  ':::';  ™  <■""  "■"'  '"•'■'  -  ™ 

"««  "S-me,!  i„,cl,  ';„r8e     T  ,     ,  j    """«'' '""l-ood  of  I04»     Tl,. 

"■' •"""■"« -0.,. „a. J;„ t;;^;-  -a.,,, ,,, „,„ .-^^f]' 

K     "*■     "«  face  was  pi„<.,,ed 


I  , 


478 


William   Osier. 


and  he  looked  collapsed ;  the  pulse  was  rapid  and  feeble.     He  had 
two  loose  movements  in  the  day.     He  sank  and  died  at  4.30  ]).  m. 

Anatomical  Diagnosis. — Perforation  ofti/phoid  ulcer  of  Unun  ; 
general  Jibri no-purulent  peritonltiK  ;  acute  nephritis;  chronic  tulnr- 
culosis  of  lun<iH  ;  lymphomata  in  the  liver. 

The  alKh)inen  was  distended ;  tiie  peritoneal  cavity  contained  tras. 
The  treneral  snrf'ace  of  iKTitoneuin  was  covered  with  a  fibrinous  ex- 
udate.  Between  the  coils  of  intestines  a  small  amount  of  fluid  welled 
up.  The  loops  of  the  ileum,  occupyinij;  the  iliac  fossa,  were  yhicd 
together  and  the  layer  of  fibrin  between  them  was  raucii  thicker  than 
in  other  jdaces.  There  were  about  30  cc.  of  tolerably  thick  pii-  be- 
tween the  loops  of  the  ileum,  and  there  were  collections  of  turbid  i)iis 
near  the  flexures  of  the  colon  on  bot&  sides.  Thirty-nine  centime- 
tres above  the  valve  was  a  circular  perforation,  3  mm.  in  diameter, 
from  whicii  fiecal  matter  escaped. 

The  first  ulcer  was  100  cm.  at)ove  the  valve.  From  this  puiiit 
there  wei'ts  numerous  ulcers  with  clear  centres  anil  undermined  edges. 
In  many  of  them  the  muscular  tissue  was  exposed.  The  iiker 
which  had  perforated  resembled  the  others  in  all  respects,  and  was 
clean-cut,  with  undermined  edges.  In  the  ciecum  the  ulcers  were 
larger  in  superficial  area.  The  appendix  was  fi-ee  from  uleeratii)ii. 
Tiie  mesenteric  glands  were  swollen  and  soft.  The  spleen  weiulieil 
270  grammes. 

There  were  old  tuberculous  lesions  in  both  lungs.  In  the  left  a 
focus  the  size  of  a  walnut,  indurated  and  surrounded  with  gray  mil- 
iary tid)ercles.  A  smaller,  retracted,  i)igmeuted  area  existed  ii;  tlu' 
riglit  luui;-.  The  kidneys  were  swollen  and  cloudy  and  |iieseiiteil 
punctuate  extravasations  of  l)lood. 

Cash  XXIX. — Mild  fecer  for  the  fird  ten  days,  then  persi.slnil  h'ujh 

teniperahiirfor  nine  day.s;  diarrhea  ;  prob<d)li/ perforation  ;  (ladli; 

no  autopxtj. 

Mrs.  X.,  aged  "JH  (Hos.  No.  10307),  admitted  July  Gth,  l.S!»4,eom- 

plainiug  of  headaehe  and  general   weakness.     She  has  been  a  very 

healtliv  woman,  and   lias  hail   no  serious  illness  since  an  aiiack  nt 

diphtheria  at  fourteen.     She  has  had  two  children  ;  no  ini>carri;ii;es. 

She  has  been  nursing  her  husband,  who  has  had  a  serious  altaek  ot 


-1  ^fudy  of  the  Fatal  Ca,e,. 


a  serious  attack  ot 


gall-.stoncs,  and  is  i„  tj,,.  rr      .    ,  '  "^^^ 

"'^  present  i||,„,,s  i„,„        ,  ;     ' -"■ 

''-'-^--i  '-aek;  noeo.!:,,,.     „:',''-. '"-'ache  an.l  pai./in 
""■■""-^'ve.     To-day,, he  <;,h  at  o,  il'^'     '^''^'  ''-^^''^  'mve 

'^-  -oating.  She  has  not  «^  ^  I  ■  ''"  ''"'  '*  "'"'"'  ^'''Jow  < 
-t  know  of  any  eases  of  iey^l^Z  '  """T  '"^''""'  -"'  ■^'-  ^ 
•"K  .n  Tennessee.  '"  "'^"  i»'^''«  "l.ere  she  has  been  st  y 

,  '^''^'  '''ood  exann-nation  was  negative      Tl 

Pa^ahle,  an.l  the.  ..,,  „,  ,  J   ^;""'  -^'-     The  sp,o.„  ,,,,  ,,, 

Dnnng  ,he  h'rst  ten  days  in  FT       v, 
■""  '^'"^^  ''ad  typhoid  feve,      ^^J  /   '"'"'  '"'  '''^^'  '■"  ^onbt  whether  or 
-^^'^°  i"  the  morni,^-a,     :  ;:';;f  "---he.th,Otha:^  ^ 
even.,g.  ^  '^"'>    Wwee„   J00°  and  loio  ;„  ^j' 

,        ^'^'••"»  thellthtothelothif  f       1     > 
;«^^  and  I7th  it  was  ..twee;/     o^;;--^  ^-T "ay,  and  on  the 

""•■  ^ '  ''  ^»  l^'-5°.    The  i,lood  w.   et ,?     '     •^'"'^  ""  ^'"^  ^'^'^'"'"g  of 
7  'nalanal  o,^anisnu.     The,"  wa    'o         "'  '■''*^^^*^'">''  ^'--  N^re 

--t,on,  .,Hch  was  p^-esent  ,„  ,1^  ,S    ""  ^^^^   '^^^'^      The  diazo- 
"0  Laths;  her  tongue  was  elea    •  ""''  ^'«='l'l«'a''«I.     «lie  had 

"---'^,I>r.  Thayer,  .l^^^Z::  ""  ''='"'•''-'  ^^''^  - 
- '■'  ;'onl.t  as  to  the  existenee  of    v,  h    d    "  """  ^'^"'  '^"'>'  ^^^'^ 
^'"  t'"'  l<^th  the  temneratnn        •'*''""'  ^''^^•^''•• 

'7^'^''<  ''----action^a„dani.^,,l^j:,^''   ^.^^^   there  was  a 
^;^^-'  to  have  diarrhoea.     From  6  n"'''"   "f  ''"^"•^'«''  -"'  «''« 

'''-■f^"'«e  only  i„  the  twen<v-fo,„.  luZ    T  '""'*''"^  ^•'"■vi"^^  one 

'"•104.5° and  105.5°.     J  d,     ./         '  ^"'''"''"  ^''^''^-'r  104°  and  1050 

-•'^  "'!a.t  in  a  ease  of  I  ii!:;.--'^'--  to  have  seen  a  LZ' 

!•-;'  sneh  extraordinar>  persi      ,     "  ^^  '^^ -^k-  «''owing  a 

";'  ''"'"■'  '^"'  "'<'.V  had  no  infl  e    7.)     "     "'  '^"  ^''""^^^  ^^'-T 


I'll    ! 


M    i 


480 


William  Oder. 


stools  in  the  twenty-four  hours.  A  characteristic  rose  rash  develoi).. I ; 
the  tongue  became  dry  and  brown,  and  there  was  sliglit  delirimu. 

On  the  25th  the  abdomen  became  .slightly  distended. 

On  the  2yth  Dr.  Thayer's  note  reads  as  follows:  "The  patient 
has  been  extremely  weak  for  the  past  two  days.  I'he  pulse  has  Um 
rapid  and  feeble,  the  abdomen  much  distended  and  hard.  There  has 
been  constant  diarrhea.  She  lies  with  her  eyes  half  closed  and  nnit- 
ters  at  times  to  herself.  There  is  snbsultns;  also  tremor  of  th.. 
tongue.  To-day  the  patient  seems  better;  the  pulse  is  slower;  tl.c 
tenrperature,  which  has  been  persistently  high,  is  flilling.and  at  n.mn 
was  100°.     The  abdomen  is,  however,  much  distended." 

On  the  ;50tli  the  patient  looked  extremely  pinched;  the  pulse  was 
feeble  ;  the  abdomen  greatly  distended.  At  2  p.  m.  the  patient  siid- 
dqnly  'collai)sed  ;  the  titce  was  pinched  and  the  eyes  sunken  ;  siie 
sweated  profusely;  the  hands  and  feet  were  cold  and  blue;  the  pulsc 
was  extremely  feeble  and  rapid.  She  could  not  be  roused  ;  the  al)- 
domen  was  distended  and  tense,  an  I  the  liver  dulness  was  almost 
obliterated.     She  sank  and  died  at  7  p.  m. 

Case  'yiHY .—Protmdi'd  hif/hftver;  on.sd  of  (Uarrlma  at  the  cud  of 
the  fifth  week;  syviptoiiiH  of  perforatioti ;  no  autopsy. 

George  H.  W.,  aged  27  (Hos.  No.  8295),  admitted  October  l>t, 
1893,  complaining  of  headache  and  chilly  feelings. 

Patient  had  been  night  orderly  in  Ward  F  for  twenty-three  days, 
and  had  charge  of  the  bed-pans.  He  thinks  that  he  has  can-lit  the 
disease  in  this  way,  as  he  confesses  to  have  been  very  careless  with 
the  pans  and  frequently  got  his  hands  soiled.  He  had  been  ailinj; 
for  about  a  week  before  he  went  to  bed  in  the  ward ;  had  coiiiili. 
headache  and  })ain  in  the  back.  The  bowels  were  constipated,  and 
three  days  ago  he  took  a  dose  of  salts.  Last  evening  he  had  a  slink- 
ing chill.  He  was  seen  three  days  before  admission  and  was  then 
not  thought  to  have  much  fevei . 

On  admission  the  blood  examination  was  negative.  The  tempera- 
ture was  104°,  and  at  midnight  reached  105°.  The  tongue  was  red, 
glazed  and  dry;  the  pulse  was  104,  soft  and  dicrotic;  the  edge  of  the 
spleen  was  just  palpable,  and  there  were  a  few  rose-spots  on  the  skin 
of  the  abdomen. 


A  Study  of  the  Fatal  Cases. 


181 

ror  the  first  week  the  p-itient   VI 
lHVh-104°,  occasionally  ]Oo°-l„!f  TT  T,'"'  ^''^  ^'^"'I'f^'-atnre  was 
<iian.h.a;  he  had  a  p-oL^  l!?.;;:.^:  :  ^^^^  ^^^^  ^^  "ad  no 

v.'ry  gond,  although  the  attack  was  prolo.,.'  ^'"  '""'''^""  ^^'''^ 

On  October  25th  the  patient  Ind  ..  T       \ 
wns  a  little  blood,  and  the  b  t  s  w^^     /"""?    ''"'^'  '"  ''^'''^'  ^''^''^ 

^••^"^^d;  bH  V  co.piai;:edt;n":?';^'^'"^'^'''^^'- 

ucro  resun  '"^  *''  "'^  «l'0'>gos  that  the  baths 

a>'.l  opiutn  enenmta  ordered     "  '"'''''  '^"'''''''  ""d  .starch 

On  the  29th  the  patient  did  not  seem  .o  well      TT 
pan,  in  the  abdomen,  chiefly  i,.  ^U,  ]„,,,,. ,  "'"•     f^^/^""^plamed  of 
appearance  had  altered  a  good  d^a     n    /        ""  ''"  '^^^  ''''^'-      ^is 
The  pulse  was  between  150  and  160  •    ,,   ''  '        ^^^-"ty-four  hours. 

-  ^-ting.     The  ten.pera..;l^^.^:  C T^^"1"'  ^1  "^ 
at  2  p.  m.  on  the  28th  -ind    I,;,  f  *     ^  ^^w  hini 

however,  was  quite  flat.     On  the  mn...  •         "^"'g''^ '  the  abdomen, 

^-1-at.ne  did  not  rise  a  bote  "040  Tl"  "T  ''!  "^"'  ^'""^^^  ^h^ 
rapid  and  he  was  bathed  in  perspi;ation  W  ''  r''  ^'T'  ^'^''^ 
p.  ni.  the  face  was  pinched   the  hX  "^  "  ^  '^'^  "'"'"  «*  3 

very  feeble;  the  1  ver  1]  J ""t  "  tT"""'' I^"'-  ^^O, 
solution  was  infused  suboutreour  T^l  -''  "'''^"'''*^^'-  ^alt 
action  very  much.     The  o"  ^Z^^^,^^^  ^  '"'^''"'"'    ^'^^   "mart's 

..egatived.     He  died  at  lO^t  "  No  ^^^  '''''  ^^''^'-'^  ^"t 


<Zl.: 


NEURITIS  DURING  m  AFTER 


TrPlID  FEVER. 


BY 


WILLIAM  08LER,  M.  D. 


[BeprintedfromrAe^oA^.^opW^^;^ 


■%»»•<»,  Vol.  v.] 


NEIIIIITIS  DURING  m  ,1FT0  mm  FEl'ER, 


BY 


WILLIAM  OSLEIl,  A|.  i,. 


JOHN  MURPHY  4  CO.,  PRINTERS, 
BALTIMORE. 


By  WILLIAM  OSLER,  M.  D. 
Any  reference  to  the  ]itoi-ifiii.«    e 
sn,,erfluo„s  since  tl.e  appearance  ,f  f^    T'    ''"''  '"  *^'''''^^'"^^   ^^^or  is 
Peripheral  JV,.cnlk  (Lon   "n     89^         ?-T  ''^'  ^^"^'^  ""•'  ^^'-v  on 
""«  given  a  very  fJl  .J^^,  [ff^.  '^^'f  'j-  'ast  nan..,  a.uhor 
raphy.     He  states,  however   that  '  H     "^      '  '"'''  ^  "''t^'"'^"'^  '^'"'''-"g- 
foreed  npon  onr  nn-„d,s  that  t'he  n  ate    .^  ZT''\  '"  ''"''"''  '-» 
oonoh,s,ons  with  regard  to  the  rehti on  ^/'"^  ■'"'""^'"" '>^"  Positive 
thecontinned  ^vers  generally  an  1^       ,1    ""'"  .•''''"''  ^^^'^  -^ 
ent  exist,  and  that  the  dootrh,    '  „  «    ;''  "T"*";'^  '""  ""^  ^'^  P'^- 
by  new  and  carefully  recorded  I W.''^.^!,''^^^^^'  ^  ^^  —  basis 

.readf2:^S;;S^:- ;-         of  10  Jnenritis  and  of  wide- 

Local  jVeuritis. 

^^^%^^:^Z:'^^  ^^'- f-  heen  .>nr  with  well- 

-'"•cl.  was  not  treated  for  the Z; in  .     u''    '  '  "^''^'^'^'y  -«« 

Before  describing  these    T  J     n      ,       ^°''^'^'"^'- 
'feasting  and  diftre'^  ^  '  ^1,  t  '^  "'  ^"^"^'^"  ^«  ^  -^ 
classed  as  a  neuritis-nanfeirt,?";^";'^  '""^^  *^'««'  I  think,  be 

When  in  the  Report  on  Tvn      .  ?^        "''  "^  '^'^''"'''^  ^^^er. 
I -lied  attention  H.^s^n    t^,    "T^'rf  '"  ^^^^  ^^^'^^  '^ 
'0  ..bject  in  the  literatu,'e    'bu     -.f  R       "''/""  "^^^  '"-^-»  of 

*Read  before  thfiN».„„,„„:.....     . 


*Read  before  the  Neurological  Societ,  of  P,,,«,elphia. 


i-, 


397 


398 


Willimn  (Mer. 


in  which  this  feature  i.s  accurately  described.  His  words  are :  "  For 
some  weeks  past  there  has  been  tenderness  of  the  toes  vi'  both  fctt, 
so  that  the  toe-nails  could  not  l.e  cut  on  account  of  the  pain  it  eau.-ed 
in  the  nail-bed  and  in  the  pulp  at  the  end  of  the  toes.  In  three  other 
cases  recently,"  he  says,  "  1  have  met  with  this  condition  of  pain  in 
the  toes,  and  in  one  of  them  in  the  arms  also.  In  one  instance  \\h' 
tenderness  of  the  feet  was  so  threat  that  they  hud  to  be  protected  IVo,,, 
the  pressure  of  the  bed-clothes  by  a  cradle.  But  in  none  of  tli.  ,„ 
was  it  followed  by  muscular  wasting  or  detinite  loss  of  sensation  s(, 
far  as  I  could  detect." 

Not  having  met  with  the  condition  before  using  the  baths,  I  wa.s 
inclined  to  regard  it  as  an  effect  of  the  cold  water;  but  in  a  pcrsomil 
communication  from  Dr.  Ilandford  T  gather  that  his  cases  were  imt 
treated  by  the  Brand  method,  so  that  it  is  evidently  one  of  these  coin- 
cidences winch  arc  so  ai)t  to  be  mi:  leading  in  medicine.  Before  .Inly, 
1890,  when  the  Brand  method  was  introduced  into  my  wards,  I  liiul 
never  seen  an  instance.  Since  then  we  have  had  twenty  or  niu,v 
cases,  all  of  which  have  been  bathed. 

Though  not  serious,  the  condition  is  very  distressing,  and  a  cause 
of  much  sutlering.  It  usually  develops  in  the  latter  half  of  the  dis- 
ease ;  sometimes,  indeed,  after  the  temperature  has  reached  nininal; 
thusi  in  a  patient  at  present  in  ward  C,  the  teiuler  toes  wciv  not 
noticed  until  early  last  week,  the  fourth  of  the  fever,  and  wlun  the 
temperature  had  already  begun  to  fall.  The  patients  usually  com- 
plain first  of  the  pressure  of  the  bed-clothes,  and  as  Dr.  Hiuuirord 
mentions  the  sensitiveness  is  so  great  that  the  toes  have  to  be  pro- 
tected by  the  use  of  a  cradle.  The  area  involved  has  been  in  nil  of 
my  cases  the  toes,  with  occasionally  the  pad  of  the  sole  of  the  loot; 
never  the  dorsum,  and  rarely  extending  as  far  back  as  the  heel.  The 
tenderness  has  always  seemed  greatest  at  the  tips  and  on  the  i)lantar 
surface  of  the  toes.  Even  the  slightest  pressure  on  the  nail  causes 
pain.  I  have  never  seen  any  redness  or  swelling,  though  of  course 
in  the  reaction  following  the  cold  baths  it  is  not  uncommon  to  see  the 
feet  extremely  red.  In  a  few  instances  there  has  been  sweating  con- 
fined to  the  feet  and  toes. 

At  first  1  thought  that  the  pain  might  be  cause<l  by  the  pressure 
on  the  sensitive  corium  of  dry  and  hard  layers  of  the  cuticle  macerated 
by  repeated  immersions,  but  the  skin  has  always  looked  natural, 


""  «'«.  I.a..  there  a,>,„.a,e.i  to  bo      v  1     '  T'"'  •''■^^'"•'-"-.  '"'.1  in 

<'"vcn>,l,  an.l  we  have  I,,.,,,,  Io,I  .rul„ ,  .'"'''  ''"^'''  ""   '■^"- 

<- '•'•ac.-0-panestl...ia  i.os.il.,v'.,„„      '  ,  ;;.;;f  "•^'  ^•'"  --'itio..  us 

'''etreatnKM.tis„ot-^ory.sa;is(iu.forv        r, 
"J'l'''r'"">""^;  thcuo  win-eh  s,.o„H  to  .J.,  '"•"  "•'^''•'  ""   ■^'"■•^  '>^' 

soh,t,on  o„  cotton  wool.  ^  '"  '""'^^  '■'■"^•'  i"^  ^  hut  .ooaine 

ijocal  neiii'iti,^  jjj  (y.,],  :  i  /• 

tI.ecIisea«e«rafbrcon-aios,.<rh.!''ir''"''' ;';■'''■■■  "^  "'"  '"'^''^  '^^• 

rapully  ai't.T  an  a.-.ite  attaek.  '  '"'  "  "'">'  l»««'^  away 

'Hh,'  two    tol|„wi„^r   eases' Mro  f|„        , 

Case  I. — /,t  ,vrco;jr/  7eerk  sfi-r,;-  0,  „       ;   • 

•*■-« «/ ■-.  '-v™*;  t :  X^^^^^^^^^^^  ""  '":""■'■"«  .• .,» .«- 

^-  n.,  aged  25,  admitted  Oetober  8    is^O      i.  .•     "   , 
-•"f'-ly severe  attael.-,  and  the  tenme  -Un  J  Im"  "'  ''^'^  ''  '""'J" 

""'  ^''"'  'lay.  On  Oetohe..  1,  '  1  '■'  ^''l  '"/.'T''  "--"'al  until 
a.Kl  while  the  te.pe.atnn.  .an,  d  ^r  t^i'"''  f^"^^'-  '-- 

gantoeom,,lainof,,ain.si„thcr.,nn  S  I  f  "?'  ^^'■^°' '^''^  ''^- 
r  ^'-  tenth  da!,  Oetobe'ur  ^n!'  ='•'""""''  '^  ^^"'<"-^'> 
clKuacter.  0„  the  Ifith  the  note  'read  '  ^'^ ■  ""''  ".'"'■'^'-''-'  '" 
very  mneh  worse,  ,she  ean  scarcely  lift  the' .r„,s  ■;r"""'"''  ''''"  '"^ 
'"S  "^  the  joints  or  any  tender,,.  .    ,  ^'"''''-  '''  "^^  «^^'t'll- 

"-.  The  soreness  i  L^  e  Hv^^  ?!  ''"'"  "'  ^'"  «'''»-^  l"''- 
once  when  they  are  ,'",  ^^  "  .^'"  '""■^^■'^-  ^^'-"  ^inL  at 
TlH-reisnoswollin.of  the  ln.n  n  .  '''''  "  ^'^''^''^''^''-Jy  tender, 
plexuses  in  the  axilhe  o.'aL  ^  JT"'.  ""  "n?""  '"  ^'"^  '^^-'^^I 
«'-otin,  in  character,  but  it  ext         7'     "  '"'"  '"-^'^'^  '"^  "«* 


JOO 


WiH'inm  Osier. 


\\ 


be  moved.  The  paiii  is  continiiouH.  Tliere  is  no  disturbuiu-c  r.l' 
Bc-nsufK.n,  no  pins  and  necdlos,  no  HWoHi.iK  "f  tlu' joints;  tiu"  le^^s  aiv 
not  iminfiil."  On  tlu>  22nd  tlic  noto  mids  :  "  Tlio  iiot  ai>plic-ati..ii« 
have  relieved  the  pain  somewhat.  Yesterday  the  hands  were  (iiiite 
numl).  8ht'  says  the  haiuls  aelie  like  tootiia.'he.  Joints  not  swoll.  n  ; 
arms  and  forearms  still  very  sore  to  toneh."  From  tlu"  18th  to  tiie 
30th  this  condition  persisted  with  very  little  chan^'  She  ha.l  h;ul 
and  opium  applieations  and  antipyrin  internally.  Hie  temp  niliiiv 
meanwhile  K>-adually  ieii  and  her  general  condition  improved.  On 
November  2nd  the  note  is  :  "  Arms  very  much  better  ;  pains  still  ii, 
the  left  arm  and  she  can  move  the  arms  wH  ;  no  wasting  of  the 
muscles."  Within  the  next  two  weeks  she  improved  very  rapidl , 
the  pains  in  the  arms  graduaily  .lisappeared,  and  she  recovered  coni- 
pletelv  without  any  wasting  of  the  muscles.  The  pain  in  this  r:,se 
was  of  a  most  aggravated  character,  sometimes  causing  the  patimt 
to  cry  out. 

Ca8E  11.-/1  third  week  onset  of  severe  pahs  in  rir/ht  arm  ami  In/ : 
rapid  improvement  in  arm;  agonizing  pain  in  h;/ ;  (jreat  MnxiUrf 
ness  of  muscles;  erythema  nodosum;  recoveri/  after  ten  (/a//«. 
Mary  McG.,  aged  13  (Hos.  No.  0405),  admitted  December  4,  l,S!i2, 
about  the  end  of  the  seciond  week  of  what  proved  to  Uv  a  very  severe 
attack  of  tvphoid  fever.  The  tempc-^nre  kept  up  for  at.  unu-nally 
long  time," and  she  became  so  feeb>.  n  *,  after  the  44th  bath  they 
were  discontinued.  It  was  not  until  S  ond  of  the  otli  an.l  throMuJi- 
out  the  6th  week  that  the  temperature  fell  to  normal.  On  DceeinlxT 
14th,  while  the  temperature  was  still  high,  having  been  <'..iistiiiitly 
for  several  days  in  the  vicinity  of  105°,  and  after  she  ha.l  lieun 
sponged  with  ice-water  for  two  days,  she  began  to  complain  ol  very 
great  pain  in  the  right  arm  and  in  the  right  leg,  of  such  severity  tiiat 
she  cried  out  constantly  and  she  had  to  have  morphia.  These  attacks 
continued  between  the  14th  and  the  20th  with  great  severity.  In  the 
right  arm  the  pain  soon  subsided  ;  there  was  no  involvement  ol  the 
joints;  no  pain  along  the  nerve  trunks.  She  screamed  out  if  any 
attempt  was  made  to  move  the  right  leg.  There  was  no  tenderness 
about  the  hip,  no  swelling  of  .the  knees,  and  repeated  exaniinatiuns 
seemed  definitely  to  exclude  any  articular  trouble.  Grasping  the  leg 
at  any  place  seemed  to  cause  extreme  pain.    The  leg  was  not  swollen. 


^ruri,,:  Dun,,,  and  AfUr  T,ipl„M  F.,er.  40, 

On  tlio  18tli  tliivc  imtcli<.«   i;i,-.       .1 

^"■' ' -« «e  .1  ";I::;.   ■S'^in';:'-:";; '-■«'  -  «■« 

>-!.  TiH.  loou  i :  L"  ,;;;;:  ;•■:  ^'-^  •>•;'-  -a  1...^ ....  ..• ., ' 

.listinct  biuiHh  .ii.....o.;;ir  1  ;  ':;^.r'' """:'  -« ^'--^  -- « 

a  .lay  or  two.    Tlu-  larger  one  c>  ,  tlu    h  ■         '  •.""■V''^"!'!'""'-^"'  ^vitl.in 

tlio  pain  accu-atolv.     It  w,s  ..o,  ...   I    •  ''  "'''''  ^"  '•"'''''^^^ 

«<Matic  nerve.     It  was  c,„ite',UK-on  ■  1  tlVl      '"  '1"'  '''""^'""  "'"  "'« 
After  <.n«in,  great  anxiety        !  .    ! '    '    '^  ""^^'""f  '>"^  "-Pl-i.. 

•"•arly  ten  , lays,  the  pain  ,snl)side,u;  '  """  •"'^'■••"^'  ''"• 

or  2ml,  two  weeks  a    least     .ntV  '''-''l--^!  ''y  tlu-  2.0,1. 

/-'-«- pain  was  l,:;:!;:;:.::::-^^^^^^^ 

trenie  sensitivenesH  on  pressure  , <;     i    ^     '"*""'  '""'  t'"'''f'  "as  ex- 

»-  r"'-  -"-i»  "..r:,:;:;,:;:;:;: : :;  f  ir;.,;  r ; '«•  •'■'- 

niiiiil)ncs.s  and  tinirlinLM'n  fin.  «..,.«.. .      ii  '  "''  ""-"'■*'  ^^as 

™»  panned  ,l,e  peculiar  l«i,"         ^         ,  ''  ™^"""r-    ™o.c.o„„d 

on  suddenly.     Vi.ere  w  scl.W  n.^        V  ''"  '^'^  ^'^'  ''^''''^'  ^'-'"^ 

t'-  i-teri^.  tibial,  i:!  '^^^^^^ir^^r  7^^  'r " -r^  ^^"-^^^ 

ens  muscle.     The  toes  wero  -I  •'  ''''""^'  '''"^  ^'^'•^''■«  anti- 

— in  then:  i;.::^;^  r^:,: h:'  '^^r^^^  ^  ^^"'"-^  ^^ 

it  .^eemed  probable  the  natient  ^v         •  "'"'''*"'"  J"''''-''^'^^'  ^^''^^ 


i   i 


U   1 

11' 


402 


William  Onler. 


tenderness,  and  the  sensitiveness  in  the  anterior  tibial  muscles  iiad 
disappeared. 

Case  IV. —  With  nmet  of  convdIc.Hccme  soreness  and  pains  in  limhs, 
jjarticularli/ the  arms;  'pins  and  needles'  in  left  foot ;  sivcllimj  a ud 
tenderness  of  left  arm;  gradual  improvement  and  reroverij  icitluml 
atrophy. 
Wm.  McM.,  aged  32  (Hos.  No.  6329),  admitted  Novcmhor  liltli, 
1 892,  at  about  tlie  second  week.  The  attack  was  of  modeiate  severity, 
the  temperature  ranging  between  103°  and  104.5°,  and  not  falling  t^i 
normal  until  the  fifth  week.  Just  about  tlie  time  the  temperaimv 
became  normal,  that  is  on  the  12th  of  December,  the  patient  coin- 
plained  of  general  soreness  and  pains  in  the  liml)s,  i)articuiarly  in 
the  arms,  and  he  winced  on  pressure  upon  the  forearms  and  anus. 
He  had  been  in  very  good  condition  and  (H)nvaleseence  seemed  well 
established.  The  grasp  of  both  hands  seemed  weak,  but  particularly 
the  left,  and  he  complained  of  a  sensation  of  pins  and  needles  in  the 
left  foot.  There  was  no  tenderness  along  the  nerve  trunks;  no  pain 
on  pressure  on  the  muscles  of  the  calves;  he  winced  a  little  when  the 
muscles  on  the  right  thigh  were  pressed.  On  the  17th  of  DcccnilKr 
the  note  reads  :  "  J.eft  arm  looks  somewhat  swollen  and  feds  tcnsv. 
It  is  not  red  ;  the  temperature  is  not  elevated.  He  moves  the  nui>- 
cles  with  ditliculty  and  says  the  arm  is  very  sore.  On  the  inner  i)art 
of  the  upper  arm  tlun-e  is  very  great  tenderness  along  tlie  comv-c  of 
the  brachial  artery  and  of  the  nerve  trunks.  The  idnar  nerve  is  also 
somewhat  tender  at  the  c'bow.  There  is  tenderness  of  the  nuisclrs. 
particularly  of  the  biceps  and  of  the  extensors  of  the  ui)p(r  arm. 
There  is  no  anesthesia,  no  sensation  of  pins  and  needles.  All  move- 
ments in  the  lin\b  cause  him  pain.  There  arc  flying  pains  in  the 
legs,  but  no  swelling;  no  tenderness;  knee  jerks  were  increased;  no 
airkle  (•'■  nus."  The  swelling  and  tenderness  in  the  left  arm  grad- 
ually disappeared  within  ten  days  and  there  was  no  wasting  of  the 

muscles. 

In  bjth  of  these  cases  there  was  great  sensitiveness  of  the  nerve 
truidvs,  and  in  Ckse  IV  it  seemed  for  a  time  as  though  the  patient 
were  about  to  i  ave  an  attack  of  multiple  neuritis,  but  the  symptoijs 
became  localized  in  the  left  arm,  whicii  became  swollen  an^l  exqui- 
sitely tender. 


Ill  rauscles  liiiil 


^^euritU  Durinq  and    ifu.   7-    ,    -, 

./  "m  After   Jyphoid  Fever.  ^qS 

oonvalesZl;  Z^^rriiro/'  M ''V''  ''"  ''''^'  ■^'"''  '^'"^'"^ 
OradunJ  veeorern.  '  ^''''  '''"''^'•'-  /"o(-drop; 

ficu  ty  ,n  wall<i„.  and  pain  i„  H,e    i.  li   t  ''"■['/'""'''''"■"■■'J,'  of  dif- 
^^'';^-'.     Tl,e  fa,.i,,  ,,,,„,,  .;i  f  '<^^-      lie  is  tho  sixth  of  six 

He  lias  always  been  a  v,..-,"     .•" 
m^^asJesan.l  „.„„„..     '        '   ''""'  ^»n^l  ■^^t^-ong  du-|d.     Jf,  ,„.  ,,.,^, 

-''l<li-l.  "''"' ^=""«  ^""^V^aid  to  be  typhoid 

.    '^'^"'''^''■^'^^'"^^^^••al.o„tsivu'o,.|-s,l      r         , 

""P'-vo.     He  ha,l  somo  ,li,HeuIty  i . "k  '  1       'T    •"  '"''  '"'  '''^^-'  f<> 

V"""';  "■"«'  ^-•>'  "HK'h  of  the  ri-d  t  folt   :     .""'f  *  ^"•'^'■^  "IN  -'-n 

evidently  ^•e,,.  sonsitiio.  Ho  vo  \,  /  '.  ''"'  '^''^  <'"'''  -><'  u-s 
''^  -'^'  "ot  wallc  npon  it  Ti  J  /,  '"•■'""'^-  '""'■''  ''^  -d 
al'le  to  got  aiK>nt  on  it  with  a  l!;;;f  "'"'"^  ""'•'-■"''  -<'  ''"s  heo„ 

IVsont  Condition.— The  pI,;i  T  •" 
Ti.e  intoiJigonce  is  good.     The ^ n^He     n    '^  ^''"'^  -'i-nonnshed. 
scorn  por/oetly  normal.     I„  wal  '        H  '? '''"'^-•"'' ^'^"^''^  My 

"-•     The  f;,ot  is  held  li„ ,,       '"  f,    ''^  ^'^''^  '^^  '«  Aexed  at  tlie 

P'^'"-     On  examination   the  n^l  V    '' ""' •^^^""'  ^"  ^■"vo  any 

•^"■='"-'  ^''-  tl.e  left.     H    L   I    t  ?         :  ''"'  '^■"^^'  ''^  <'--'Jedly 

-'>-"''^'-  '"-'OS  hoiow  th .  r  ;r"  nr  r'""^^'^'--- '" 

«^-'">""ation,  as  he  cried  out  .nd  se.,I    T        ,','""  ^"  "'"'^''^ ''  P'-<>Per 
^^-•''-^  l^ut  this  is  apparently  :eX^;^;"'  ^""^^  ^''^'  '^^' ^'>  be 

B"'T'.s  article.  '   "^  '■o^^'reiices  are  to  be  seen  in 


I    I 


i  i 


404 


William  Osier. 


Tin's  localized  atrophic  paralysis  after  typhoid  may  be  due  to  polio- 
myelitis, and  the  distinction  between  the  central  and  peripheral  nature 
of  some  of  tiie  cases  is  often  very  obscure.  Sudden  onset,  sensory 
disturbance,  and  permanent  disability  in  certain  of  the  muscles  of  tiic 
affected  limb,  speak  for  a  central  lesion.  The  case  reported  by  Shore 
(St.  Bartholomew's  Hospital  Reports,  Vol.  XXIII),  is  perhaps  the 
most  satisfactory  on  record,  as  showing  conclusively  the  existence  (jf 
acute  polio-myelitis  in  connection  with  the  atrophic  paralysis  follow- 
ing typhoid  fever.  In  Case  V,  while  the  general  appearance  of  tli.' 
limb,  as  the  boy  stan.ls,  is  highly  suggestive  of  spinal  paralysis,  yet 
the  gradual  onset  and  the  extreme  sensitiveness  are  in  favor  of  neu- 
ritis. The  reaction  of  degeneration  and  the  absence  of  the  reflcxt's 
are  symptoms  common  to  both  central  and  peripheral  lesions,  l-'or 
the  tiiird  and  most  important  diagnostic  criterion  ;  viz.  :  the  complete 
recovery  or  permanent  disability  in  certain  muscles,  the  time  which 
has  elapsed  has  not  been  sufficient. 

Multiple  Neuritis. 

The  most  serious  forms  of  paralysis  following  typhoid  fever  lU'C 
those  in  which  there  is  a  rapid  or  gradual  development  of  paralysis 
of  the  legs  or  of  both  arms  and  legs.  Cases  of  the  parai)legic  tyjie 
are  not  infrc(iueut  in  the  li^'raturo.  In  my  own  practice  I  liavp, 
however,  never  met  with  an  instance,  ^yidespread  loss  of  i)owor  in 
all  four  extremities  is,  if  one  may  judge  from  the  recorded  cases,  vuiy 
much  less  common;  but  within  the  past  two  years  the  following  caso.-^ 
have  been  un     r  my  observation. 

CaseY I. —Severe  fever  of  three  weeks'  duration ;  during  cnnealescence 
weakness  of  arms  and  legs,  nnth  finally  complete  paralysis;  foot- 
drop  and  wrist-drop;  great  soreness  of  the  muscles;  progressive 
improvement;  complete  recovery,  after  persisting  Jor  more  than  a 
year, 
D.  S.,  male,  aged  9,  applied  at  the  Neurological  Department  of  the 
Disi)ensary  November  1st,  181)3,  Nsith  paralysis  of  arms  and  legs. 
There  is  nothing  of  any  moment  in  his  family  history. 
He  was  always  healthy  as  a  child.     He  went  to  school  1-t  winter 
and  developed  well  in  every  way.     I^ast  July  he  was  in  b.  1  three 


^'euritis  During  and  After  T,j,,,;,i  j,^^^^ 
weeks  with  a  fever  <<..  I,?  f    i  .  ^"^''  ^^'^ 

J/.0  mother  think,  that  Ihis  ,.Z  '"'  »'"" I  k,m  f,,pl 

He  ha,  „„t  „,„,„,  ,,.„^^ , ;; '  -  ■■»™  .1.0 ,., ,„,  Zi 

power  i„  then,  alloMhoV      H,    f  '  "'"'  '""  »™l<s  ••■•'o  h,.  I„^ 

rile  notes  „i,ich  Dr.  H    JI     *'' "' l"™'' m  both  arms  and  |e,„ 
l'A%  as  follows :-  ''  ■""""""  '"1<  at  his  „,„  ^^''^^ 

-■t  well      The  shc:.ulcler.gir,l,e      tlj      ""T'"  ""^'"^'  ^'-  '-ad 
-ountof  st.-e„gth.     The  deltoids  a   "^  't'^''^'  '''"'  ='  ^-^ 

t  elbow-jo.nt  are  somewhat  weak  o„    ,  i',    ^^'""  ^'"<'  ^-^-sion 
longus  does  «ot  act  o„  either  ,si<le     Bel     '     '^  f'^'     ^'^  supinator 
P'  power     The  hands  arc  i„  tv  >ioa  ^  I'?"""  ^'-'^  '«  -aroelv 
Je  extended  in  the  least.     He'i      1     ^       '''  ^'''''''''  ^"''  ''^nno't 
fip  on  the  right  .^ide  and  tl  C  „d  t  H^  ^''^'  ^^  -■^'^' 
i  ere  are  no  n.oveme„ts  of  the  s,,  d  ^n       1      '  ^"^'^^'^  ""  ^'-  '^ft. 
w  .ole  arn,  and  fore-arn.  are  v^";        T  i!     "  "'  ''^  ''^""'-     The 
ri.e  sku,  over  the  last  phalanges  is  "iittl  T'  ''  'i'""^^  "«'•«'«!. 

'!  <-  of  the  table  the  back^  is    ci  J  d      ;?     '    '''^""  •^'""'■"^^  «« 
^V^l'en  on  the  back  the  mtwnf  J     .     '  ''"^  "'"""»*  .sit  straiTrht 

;..ie  of  about  450 ;  :i.rtft  ,;:;;,^:,.^r"  '^^-"  ^'-^  bod,::t^ 

I'as  3o.„e  power  in  extensors  an  f   I    ^""  "'''"'  *''«  '•''^''t.     He 

;;  -'i  -'t.  The  extensor  rusdes  :f  t^ '  ^^^  ^'^"  ^^^^^  the  ,e^ 
t  ^  fl-ors  are  the  weaker.  Be Inv  te  l'" '"  T '  ""  ^^^'^'d-; 
P'eto  paralysis.  He  can  slight,;  fl"  ;""!  ^'^^ '«  «'-ost  com-' 
'"'^■•k^'Uy  atrophied.  I„  .vaJn.n  V  ^''''-  ^''^h  legs  are 
:^;«  f  pain,  also  wineer  ^  :  ^7''"^  '''  ^^^'-'^^  "- 
0^  the  orearn,  also  are  slightly  "22Z  •'""'*^-  ^^''^  "'"^^'^^s 
cannot  be  obtained.     The  mnsdi!  ^"'''''"■'^-     ^l.e  knee  jerks 

->•  ^"•S'^^  to  the  galva^ t  .:;" Vr  ?•  '^'•'''"■■^'"'  ^"'^^  ^^ 

'^nt.     The  pat.ent  was  ordered  the 


406 


William  Oder. 


syriip  of  the  iodide  of  iron,  m.  xv  three  times  a  day,  and  massaj^e  with 

electi'ieitv. 

On  Januaiy  12th,  1894,  the  note  reads :  "  He  lias  heen  given  elec- 
tricity three  times  a  weelv,  and  has  improved.  He  can  now  \.alk  a 
little  alone.  He  has  a  very  typical  'steppage'  gait.  There  is  still 
complete  foot-drop.  The  muscle  groups  are  still  sensitive  on  iinn 
pressure.  There  is  still  the  reaction  of  degeneration  in  the  nuisdcs 
below  the  knees.  The  muscular  strength  in  tiie  arms  has  improved 
very  much.  Ho  can  Hex  the  wrists  with  a  fair  amount  of  i»o\vei." 
Throughout  the  early  part  of  the  year  the  hoy  did  very  well,  and 
there  was  a  progressive  improvement. 

H"  came  to  the  Dispensary  on  the  24ih  of  August,  when  it  was 
noted  that,  though  he  still  drags  the  toes  somewhat,  the  gait  has  Inst 
its  typical  character.  He  can  move  al  the  muscles  of  l)oth  arms  and 
Ic's  and  has  considerable  power.  All  the  muscles  respond  (piickly 
to  the  electrical  tests. 

On  December  1st  Dr.  Thomas  made  the  follow   .g  note:  "Legs 
are  well-nourished,  and  he  moves  them  in  every      -(ction;  he  can 
flex  the  legs  and  thighs  fiat  to  the  body,  and  resi  .s  extensi(.ii  very 
well.     The' flexors  of  the  knee  are  strong,  but  not  so  strong  as  the 
extensors.    When  the  foot  is  extended  it  cannot  be  dorsa'Iy  flexed ; 
when  raised,  however,  it  can  be  easily  extended.     In  the  arms  all 
the  muscles  act  normally,  but  the  flexors  are  stronger  than  the  exten- 
sors.    This  is  especially  true  of  the  wrist.     The  mu.scles  of  the  legs 
respond  to  the  faradic  current;  the  flexors  respond  to  a  third  higlior 
current  than  the  extensors.    They  also  respond  to  the  galvanic.    The 
extensor  and  flexor  muscles  of  the  arm  respond  promptly.     Sitting 
the  boy  still  has  a  tendency  to  bowing  of  the  back  and  to  toe-diop." 
I  showed  this  boy  at  one  of  my  clinics  in  January,  1895,  wlieii  he 
seemed  well  in  every  respect,  and  the  only  abnormality  to  be  detected 
was  an  inability  to  raise  himself  readily  on  his  heel  .  his  toes. 

Case  YU.— Severe  attack  of  I  i/phoid  fever  ;  durinrj  "onvu  :mncepro- 
yreii,sive   loss   of  power   in   «m.s   and  legs;     recovery  in  < inns ; 
atrophy  of  leg  wiuscfes  toith  foot-drop  ;  great  improvement. 
Wm.  E.  K.,  aged  24,  admitted  October  16th,  1893,  complaining 

of  inability  to  walk. 

The  family  history  is  good.     The  father  and  mother,  and  one 
brother  and  three  sisters  are  living  and  well. 


\  massage  with 


Neuritis  Durinr,  and  After  Tunk^id  P 

"'•'^"'a'  <l'-aso.  Dnrfng  eol.vale  '^  V''"'  '  ■  ''""'''^''^^  '>^^'- 
"•e  luuKls  a„,l  in  tl.o  1,.^,..  Tlu-  ,1,11  '"  '-'•"'^•^'^•^"  '"'^^  "f  power  i„ 
;"'^^7'  •'""'  '-^  --S  net  until,  faylfth  !•"':, t  '"'  ^""^'  ^■■"'^'  '><"i- 

•■'^i  '-I  .nneh  pai„  .,-,1.  th.  attack   1„  ""^ '•^■'"-"'--  that  he 

^  -  ^-t  Dnrin,.  the  present  ye^rt  ,  "'"'  T''^  ^""-"  ''^"-'Jin^  of 
«'"-'y  ■"  the  logs,  bnt  it  has  l^l^lr^,^:^,  '"?  ''^^"  -'"-^"^ 
-vere  pan.nychia  in  hoth  big  toes  'h?  "'  '^  ^''''  ''-•"'"PnK.t  cff 
powor  con.pletely.  ''  -"  ''*"  ''*'"<'■'*  ^'kI  arms  recovered 

Condition  on  admission  — Tl 
.    -l^s  uith  crntches.'    h;  has'^H^r  ^n ''""'^' ^""'-'^  "-' ; 

He  looks  a  httle  pale;  the  pnpi,,  .,.   e'  nl  .    \"  '"^'"'^'  "^  '""«  ^'a-. 
accommodation.  '    '  "^  "^1"'^'  ^nd  react  to  light  and  on 

The  exan)ination  of  tl,„  >i  1      •     , 

appeared  to  be  weaker  than  ^X^J^' "^^^     ''''^ '^''^'^^ 
he  arms  were  weaker  than  the  ^  .1       r     '  '"''  ^'"^ --tensors  in 
"•f  ™  "«^  q">-te  as  strong  as  i  o  e  of  1^  "' •".''"'"'^  ''^  *'"^  ^^^ 
marked  wasting  in  the  muscles  of  tiT  '"  '■'-''^-     ^'*  <«^  was 

-•  '-^-<J-p.  Correspo::;; :  tZ  hZ •^^"^""'^^'  ^^''^''  ^■'^" 
''"•l';v--.  The  legs  co.dd  I.e  flexed  an  ,'V'f;"''  '""  "^--- 
«"•'  the  thighs  flexed  npon  the  abdom?  "'''''  "'"'"  *''«  thighs, 

^^'■™  tl.e  patient  was  trving  o    .«".?'''''  ""'■'^'  ^"^  '"^'^  -- 
"'-t  marked  loss  of  power  is  in    hi"     !      ^'"''^''^  "^''"J'''^'  a-'fi  the 

- «- ti^e  foot  at  the^n^^ ;:,  tr  ::t^  ^'^''^"  ^'■^^-  ^^«  -- 

«'on  and  eversion  possible.    Sen«a  i'on  d  '  '"^^^"^^^"ts  of  inver- 


fli 


I  I 


408 


William  Osier. 


point  of  the  pin,  with  the  exception,  perhaps,  in  vne  left  k-g,  where 
there  seems  to  be  a  little  duin-ss;  he  ,ii.i  oguishes  heat  from  cokl. 
The  knee  jerks  could  not  be  obtained  ;  auide  clonus  was  nut  present. 
The  reHexes  in  the  arms  are  present,  and  ;v.e  a-  :.ve.      I  here  was  r.  - 
action  of  degenerati.;a  in  the  atrophied  muscles.     Thei  e  is  no  ;nvolv- 
nunit  u'  t:..  bladder  or  of  the  rectum.     The  patient  was  given  persMl- 
eut  muK  .-i'"^  and  a  strychnia  tonic.     The  big  toes  were  first  ufi^at..! 
upon  for  Cue  co'.uiition  of  ixronychia,  and  they  healed  readdy.     The 
patient  re.!'-'J.-d  m-lor  observation  nearly  six  months  and  improve.l 
in  every  wav.     By  tht  middle  of  December  the  pc. '?er  seemed  fully 
restore  i  in  the  arms  and  hands.     The  deep  reflexes  were  still  a  little 
increased  t^The  patellar  reflexes  had  not  returned.     The  extens.u- 
muscles  of  the  feet  had  not  yet  regained  their  full  ^  '>wer,  but  both 
feet  could  be  flexed  somewhat.     The  patient  had  a  tvpical  steppage 
gait  of  foot-drop.     Throughout  the  early  part  of  the  year  he  did  re- 
markably well,  gained  in  strength  and  could  get  about  readily  with- 
out crutches.     He  left  the  hospital  May  9th  very  greatly  improved 
in  every  way.     I  heard  of  the  patient  through  Dr.  Scott,  on  January 
16th,  1895,  who  said  that  the  progress  continued  satisfactorily. 

Case  VIII.— i^ew  of  four  u-ceh'  duration;  numbness  in  legs ;  swhkn 
onset  of  paralysis  in  arms  and  legs;  gradual  improvement  in  arms; 
slight  in  legs,  in  which  the  paralysis  recurred;  marked  improvemait 
under  treatment. 
Stephen  T.  McK.,  aged  25,  admitted  November  4th,  1894,  com- 
plaining of  loss  of  power  in  both  legs,  weakness  in  the  hands,  and 
pain  in  the  lower  part  of  the  back. 

His  parents  are  dead;  the  father  of  bilious  colic;  the  motliorof 
pneumonia.  He  has  two  brothers  and  one  sister  living  and  well; 
there  have  been  no  nervous  troubles  in  his  family. 

The  patient  had  measles  and  whooping  cough  as  f 
monia  when  thirteen.  In  June,  1892,  he  had  typhr 
confined  to  the  'a>use  for  seven  weeks.     F    hart 

years  ago.  , 

Present  illness.— In  February,  1894,  the  ^x  ^^nt  had  a  protracted 

fever,  which  lasted  four  weeks.     He  had  vomu,;;.?;  no  diarrhoea; 

uo  convulsions.     He  had  some  sweating;  no  chiii  .     [le  had  pain 


'   kl.  and  pneii- 

er,  and  was 

.;norrh<ra  three 


mmMsimm 


left  log,  whore 
eat  from  cold, 
as  not  present. 

I.  here  was  n  - 
»  is  no  involv  - 
s  given  persi  it- 
;  first  u[ii:rate(l 

readily.  The 
j  and  improveil 
er  seemed  fully 
'ere  still  a  little 

The  extensiir 
^ower,  but  luitli 
ypical  stei)i)at;e 
y'erjr  he  did  re- 
nt readily  witli- 
i-eatly  improved 
:ott,  on  Janiuiry 
sfactorily. 

sin  legs;  sudden 
->vement  inaiias; 
•ked  hnprovemfut 

4th,  1894,  com- 
the  hands,  and 

; ;  the  mother  of 
iving  and  well; 

.•b'ld,  and  pneu- 

id  fc-'er,  and  wiis 

..norrhcea  three 

had  a  protracted 
g;  no  diarrhoea; 
i.     lie  had  pain 


-'™'';«.  "eiow  U.0  elbo^tllC  "nf  1,.,",'""^  ''"'"-" 
pm«  anil  needles.  There  wn,  „n  „o  t  .'•,'""'»  ^'Kation  of 
IWal  „,„«,,e,,  „,„,  „„   ™,™„   I  '""'>••;"  <"  "'0  «""B..c,  o,-  „f  tl.e 

;ive  t,«  .„e  <^,,„  o/::i;r  ::t^^^^^^^^^^^ »» -<•"•=  p«'- 

l.e  .nsists  ca„,e  on  in  the  con«  of  I  Z  °*  ''""'"'  >"'''"'' 

W  l.«n  han,i,$  Uown^  T'le  ^    'l;  tr^l  "™"  ""?  '""^ 
ays,  loss  of  sensation.  ''  '     '^''""■'  ™  also,  lie 

.1, '':™t-  T^ersirirrr  '"■'""^^™"' '» "-  """.-'ion  of 

The  sensalion  in  the  fot '  "!,  r  ""  "''''  '°  ''''«'  ''''"»lf- 

:"rsS.'"^:t:;;t';:"''7v^'-°-^^ 

again  the  power  of  isH;     e  e^'  ^^   ht':'  '^^"i''  T'^  '"'^^  '"»' 
lion.    Sinee  then  he  has  lielnf,  '^  "I'slucbanee  of  sensa- 

^Ngl.%,b„t  is  still  n„aWe';?;:a,r  "'°'""'  '"  ""  '"-«  ""  <•«' 

*aH.  and  well.    Lr.  isr-in^Kr    -^'rE^'r:"' 
Ihe  |.n|„ls  are  equal  an.l  the  iris  reflexes  are  ,„e,e  °''' ' 

Jlic  examination  of  tlie  aMomiml  »nd.i.       ■ 
Tkere  is  no  enlargement  of  re,ee„     ^^T  T" ''' "''«"'™' 
«ell-nourished  ■  the  snine  V.    7     T        ,       '  "'""''  """"'^  '"ok 
III.  hands  looi       oTnt  t li  ,.!      *    '  "'"',  "'™  '■'  "°  '»<■""«• 

xiusi^its.     All  tlie  movements  are  nerfeet  .,nrl  fi.„ 
"-  -.gers  and  the  grasp  of  the  hands  are  S      Tl    ^"""/" 
seeni  to  have  recovered  Pnm..l.f  i     .u       .   ,  ^  ^'^^^^  muscles 

^0  strong  as  he  w^.  ''"^^'^'^^>''  *^«"g^  ^^  says  he  is  not  nearly 

9 


410 


William  Osier. 


The  logs  are  very  thin,  particularly  below  the  knees.  All  of  l\w 
muscles  are  here  very  much  wasted.  The  legs  can  be  moved  freely 
at  the  hips  and  at  the  knees.  There  is  complete  foot-drop,  'llio 
patient  can  neither  move  the  feet  nor  the  toes.  The  knee  jerks  a... 
absent;  there  is  no  ankle  clonus;  m.  ledema ;  the  feet  feel  cul.l. 
There  are  no  fibrillary  twitchings.  The  sensation  is  everywhere 
iwrfect  to  heat  and  cold.  The  electrical  tests  show  the  reaction  ol' 
degeneration  in  the  peroneal  nerves ;  the  extensors  cannot  be  m;ul. 
to  act  at  all.  The  gastrocnemius  and  soleus  show  marked  reactidu 
of  degeneration.     The  arm  muscles  react  well  to  weak  currents. 

Patient  was  ordered  strychnia  and  massage  to  the  legs  twice  duily. 

Throughout  November  and  December  the  i)atient  improved  rapidly. 
He  was  soon  able  to  walk  with  a  stick.  The  feet  have  perspiivd  a 
great  deal,  and  they  get  very  red  after  he  has  walked  about  on  t\mu. 
The  gait  had  the  typical  steppage  character  of  extensor  paralysis. 

By  the  first  of  January  he  could  walk  without  a  cane.  On  Nd- 
veraber  18th  he  weighed  102  pounds;  he  gained  rapidly,  and  m 
December  10th  he  weighed  118  pounds,  and  on  his  discharge,  .Imii- 
uary  28th,  1:35  pounds.     His  improvement  was  satisfactory  and  i.ro- 


gressive. 

On  December  4th  the  electrical  reactions  were  as  toilows 


(Dr. 


Oppenheimer.) 

Arms.— All  muscles  and  nerves  react  well  to  moderate  currents. 

Legs.— The  peroneal  nerve  of  right  leg  reacts  well  to  modci  atoly 
high  faradic  current;  contraction  slow,  but  does  not  give  the  typical 
reaction  of  degeneration  which  it  did  on  previous  oc'casions.  Muscles 
of  the  right  leg  do  not  react.  In  the  left  leg  the  contraetiou  ol  the 
peroneal  is  slower  and  lazier  than  that  of  the  right.     The  muscles 

do  not  react. 

To  the  galvanic  current  the  peroneal  nerve  and  the  muscles  react, 
and  there  is  a  sharp  contraction,  not  particularly  slow. 

At  the  time  of  discharge  he  had  gained  33  pounds ;  lie  still  had 
the  characteristic  gait  of  extensor  paralysis.  He  had  not  rc-imed 
much  power  over  the  muscles  of  the  toes.  He  could  fiex  and  cxleiu! 
the  <M-eat  toe  of  the  right  foot  only.  On  the  left  side  he  could  move 
the  "toes  a  little  better.  He  could  flex  and  extend  both  feet,  and 
abduct  and  adduct,  but  not  to  the  full  extent.  The  legs  at  the  mid- 
dle of  the  calf  had  gained  greatly  in  circumference. 


e  niu.seles  react, 


Case  IX._,v„„.<,  „„„^,^, 

raeiit,  a  very  severe-  attael-  -w  i  ""-"^'y^  ^••')iii  |,  ,^  fiiti,,.,.'     .  , 

AU.M„e  end  „f  „„  S    ^^J-;  .Wino,,,,  .„.,  uj^^t^: 

gradually  grew  worse  nnlil  tl,e  ,i„„  'f        "  ™  ™'-     ^i'e  comlitio,, 

*'  «   no  reaction   .r  Jegenerati,,    •     ',     '  '''"'"'^'  ™,„i„a,i„„ 
™ark«l  reaction  of  iegenerali™      ,  °™  ""«*'.  l"'!  a  well" 

,   P"«„t  co„ditio„.4)„  adtl  "  '*  ™"-*'^'- 

'"'V""  i-'-'^  ""..mw  hr;;;:"'r"™'  '•"'■aw.v>veii,„r„w„ 

S"l  ™lor;  the  ,„,,i,,  arc'  of  ^  ;'".'°""-  '"™>l'ra..«  L " 

" '^"""™'-''"'-'--:2sr;ii';,^.- 


412 


William  Osier. 


The  examination  of  the  abdomir'  ,.  '     -      mc  or,n.ns  .s  neguln  .. 
The  .ph-en  is  not  enlarged.     B..lh  arms  and  legs  1.k.k  atroplued 

Thire  is  no  wrist-drop.  All  n.ove.nonts  ot  the  hngers  hands  and 
arm,  are  perfect.  The  grasp,  however,  is  extremely  teehle.  ihe.v 
is  n-  sensitiveness  alon,  the  oonrse  of  the  nerve  trnnks,  bnt  th. 
Inscles  themselves  are  very  tender.  He  eries  out  .f  the  arn>  >s 
"asped  above  the  wrist.  The  museles  of  the  legs  look  wa...  . 
Tl.>  e  is  complete  foot-drop.  He  cannot  move  the  toes  or  the  k  . 
He  can  flex  and  exteml  the  legs  ;  W  can  ^et  ont  ot  bed,  but  slan  s 
withalittl.-dimcnlty,und  walks  with  the  aid  of  a  cane,  drags  th. 

oes,  and  has  a  typical  steppage  gait.  The  sensatu.n  seen,s  perieH, 
and  he  no  longer  complains  o'"  pin.  and  needles ;  there  .s  no  tender- 
ness along  the  ec.rse  of  the  sciatic  ;  the  sensitiveness  o   the  .n..     ,.  s  s 

very  marked.     He  winces  if  th.  thighs  .r  calf  muscles  are  pn^s..!. 

There  has  been  no  trouble  with  the  ^Phi"f  ^ '""^'•'^;- .  ,     ,„„.  .  . 

The  patient  was  under  observation  nntd  tebruary  4th,  l89o  ,  the 
general  condition  improved  rapidly.  On  adm.ss.on  he  weighed  . 
pounds,  and  at  the  time  of  hi.  <lischarge  weighed  05.  He  recov,.,. 
power  in  the  hamls  completely,  so  that  the  grasp  was  qu.te  go.a. 
The  foot-drop  persisted,  and  he  stil  <.onld  n.t  move  the  toes.  1  h.re 
L  no  power  iir.tever  t.  Hex  or  tend  the  foot,  or  to  abduc,  .r  ad- 
duct  The  tenderness  on  pressure  had  almost  completely  disapp.u.r,!. 
The  electrical  condition  remained  about  the  same;  no  reaction  to  tl,o 
faradic  current  in  .  .le  .luiscles  or  nerves  of  the  le;,AS. 

With  the  galvanic  current  there  is  a  typical  slow,  lazy  contraction 
of  the  tibialis  anticus  of  both  legs.  ,       ,       , 

DiAGNOSis.-These  cases  of  -  uati>.v-  neuritis  were  not  under  ,.s<., - 
vaUondnSig  the  primary  il!  .  a-.,  the  diagnosis  o  typho.  evor 
rest,  upon  the  statement  eitl  of  physician  or  ot  he  en,.. 
The  only  doubt  really  is  Co..  .'HI,  a.  this  patient  is  state.1  to  hu. 
had  typhoid  fever  in  June  of  1892.  I  have  not  been  .u  e  t.  get  any 
imat^on  from  the  physician  who  attended  him,  but  his  illness. as 
e^dently  very  severe,  as  he  had  fever  of  four  weeks'  duration,  w.tlu 
dbrrha^a  and  without  chills,  and  the  paralysis  did  not  come  on  m,  1 
coalescence  was  established.  In  Case  IX,  in  the  third  week  oi  the 
illness  the  lather  noticed  the  soreness  in  the  legs. 

The  mode  of  the  onset  is  of  some  importance  in  the  diagno.s.s,  sine. 
there  are  cases  of  multiple  neuritis  which  set  in  with  fever   ukI  id 


azv  contraction 


Nmritk  During  „„,  ,, .  ,.  . 

H  ».„„,,„, , ,,,,    J,^-  '.;;"«!.  1,0™,,,,,  „,„  „,,„, 

'•'"<'  •'•■'inimi.     He  |,p„„,„„        ,.     .    '^ '""""' sflnrat  on. 
--  never  at  an,  time  svn.pt,  „,  ^  '  "r^'^^'^'  ''<''l>''  -■  »>"t  U.r 
V  re  not   ,„volved.     TIh-,.' n^  1     '    '"  •  '^^•'"•-     T'- splunctors 
-"g'-ut  Xovo„.be..and  Do,J        ,""''"^  "^"  '^e  extre,„i,os. 
=^">-  able  to  get  about.  "''"  ''^'  ""Proved,  and  was  gradu- 

^Vlunadmittod  on  January  2nd    180^  ., 
-;-     Ho  is  a  pa).,  dolieato-  0:1     :,  S  '  *''«„-"*' ■■^'"n  was  :.  fol. 
r'T"^  gai^  flopp.,..  ,,  ,,,,  ,,^  ^^  '-J     walks  .itb  a  ve,y  distinct 
t'-iae«aet  ..onnally.     Then-  is     o  i,.!'""'''''^'^  "^  *'"-'«>•««  and  of 
"'"^^'^«-  ■  muscles  of  the  h   .d  an        \'""""'  "'  ^''^'  P''"'-v..geal 

-eeasdysh,    ,,.,,  ,„,  resist  fl^^^  The  sho-ulders 

0'  tl>e  shonl,le..s  also  act  wel       oPf      '"''''"'•     '^'^^'  *''^i'— 
strong  on  both  sides.     Flexi,;,,  „  h      [ ''"''"'  "'^  P^^^^''^'  muscles  are 
0"  both  sides.     The  .nu  X  0 f  1.!      "■'""  ''  ''"-'  ^''^--  -e  go  d 
are  feebly  developed.     In     L  L       "T"'  "™  ^"^'  ^'">"'<'-  -nil 
-ak;  paIn,a..rteiion  is  a^o  t  r'lt    T'  f^'""  ''^  "^  ^^^^ 
He  's  entirely  unable  to  extend   h.:  fi  "'  *''""  ^''^  ^'«'--'  A^^^'on. 

^-   i-'i"ts.      [/•  these  Jointr  .  t^T  '"'  ''l  ""■^'-n-phaian- 
;  '^^''tly  extend  th.  .....nin...,  phd    :">;''"''"''  ^''"  '^^^^-^  -" 

J"  -nst  is  held  and  «oxed  <  ors    K^tno        r^'"'^*'''' ''^'"''  ^^en 
The  small  .nus.-les  of  both  ban  k  n  '  ^       '  ''^^^^--on  the  righr  side 
;  '•'  to  oppose  the  thun.b'lnd  1  ^  r;:;^  X'  ,  '"^  ''''^'  ^«  "^ 

';"  >■  W»H'  the  kuees.     He  ean  Hev  n    f'"^^"  ^"     thin,  partieu- 

"''"-"'«"''  the  legs  on  th      h.  .l  "ti:"'^"'  '"  ''"'^'''^  ""  ^'- 

'■  '■^"."'«t  flex  or  extend  the  feet  a  "tb        n   "  '^^''''"^  ^"^^-''''^P- 

;'f<i-t,on  of  the  feet  are  impo!si  ll      T    '  "      "'  *"'"'  '•^^^"'^^•«"  «"' 
-■  ,  The  kn<.o  jerks  are  a  s"      "The^""  '^  "'^  """"''  ^^  "^^  *'- 

.-'y-i-ere  of  the  nerve  trunks  or  o,  "  '"  T"'  -"--''vonoss 


\ 


414 


WiUUun  Oder. 


jrirdle  or  of  tl.e  ..pper  arm,  or  in  tl.e  mq  nutor  n,  the  muscles  of  tho 
palmar  si.lc  of  the  forearm.  O.,  the  dorsal  surface  the  mnsoles  .1.. 
not  reaet  even  with  the  high  faradie  enrnot ;  there  .h  a  slow,  lazy 
contru<.tiun  with  the  galvanic.  The  reaction  of  degenerat.on  .s  pre- 
sent in  the  tibialiH  anticas  and  the  peroneal  group  of  nnindcs  n.  the 

^'^The  hoy  remained  under  treatment  for  two  raontl.H,  and  improved 
very  n.neh  in  walking  and  in  the  mnsenlar  power  of  the  hands.  ImU 
he  still  has  foot  and  wrist-drop. 

The  differential  diagnosis  is  between  periph.-ral  nennt.s  and  anten,., 
polio-mv.litis,  l,Mt,  as  Gowers  says,  the  distinction  of  a  central  l.un, 
[  perii.heral   lesion  is  often  very  <litHcnlt.     The  points  of  .mportan,. 

are  as  follows:  ....  ■ 

Fird.  The  mode  of  onset,  whi.-h  in  myel.t.s  ,s  very  much  .no,,. 
rapid.  It  will  ho  noted  that  only  in  Case  VIH  was  the  onset  stat.d 
to  be  sudden,  vet  in  this  very  case  the  complete  recovery  of  the  hands 
the  very  striking  improvement  in  the  condition  of  the  egs,  and  par- 
ticnlarly  the  fact  of  a  well-marked  relapse  leave  very  l.ttle  question 
as  to  tlie  peripheral  nature  of  the  disease.  ,     ,.       ,       , 

An  additional  difficulty  in  the  matter  of  onset  is  the  fact  that  t  i.re 
are  eases  of  polio-myelitis  anterior  which  set  in  sub-acntely,  and  on 
the  other  hand  cases  of  polyneuritis  which  have  really  an  alnupt 

onset.  •       ,,, 

Second.  In  p(.lio-m>elitis  the  sensory  symptoms  are  .puK"  mi1,- 
sidiary,  whereas  in  polyne.n-itis  there  is  more  or  less  pan,,  or  sensa- 
tions of  numbness  and  tingling.  It  will  have  been  not.ced  ,n  to 
report  that  the  muscles  themselves  were  in  several  rases  extr..nu.ly 
sensitive  to  pressure,  a  point  to  which  Wilks  and  others  have  .mII.! 
attention  as  specially  characteristic  of  neuritis. 

ThinL  The  atrophy  is  certainly  more  rapid  in  the  central  l.sio. 
but  it  may  reach  quite  as  high  a  grade  in  neuritis.  In  ('»..  \  11 
the  wasting  of  the  leg  muscles  when  he  first  came  under  observation 

was  very  pronounced. 

Fourth.    According  to  most  authors  the    lectrical  tests  alloni  very 
little  assistance  in  the  diagnosis,  since  the  reaction  of  .leg,.n,.iation 
is  present  in  both,  but  there  is  this  important  d.fierenee;  a.nu^l 
which  has  lost  its  faradie  contractility  in  consequence  of  des  rue  ion 
of  the  motor  cells  is  permanently  damaged,  wherea   the  lo^s  oi  laiadic 


^''urUiH  Dnrinn  and    l/>.     t    . 

./  "»'(  After    Typhnul  I>'ever  a^m 

contractilitv  ii,  the  m  ^* 

"•every  of  t  .     r  '"  "  ''^''•"'""*"'t  .'Mo,  .o  tl  1  '    T^  '""''"*' 

77  Hoasat.on,  cliHt„,i.anc,vs  <,f  h  '*'"''^'"^'  ^''•'P'"'"  <'»'aM.aN 

'^pp:'-"'  * - •-  -r;::",:;,.;;ri 

-f-i!::tr;zrr"^      h,.„. 

^^■'"^•''^«n,eumh,.  observation  V  '  '""''''''•■  ""■"•'"t'-  •     In  (Zv 

f'-7!  ">  an  inability  ,.  ,«,-,,  ,;     7;^'  ^''^   tho  only  n.nn.ant  ufus 
'"  ^^•'"^•''  tl.o  paralysi.  ancl  a  r     '  "  '"'  ^'''^'  «''  t"''^-    ^  ^.v.  1 7/ 

"-at  ti.e  naralvsis  ll.  """"'•>'  '^"f''  '>''  tliis  veir  ■,»     >  ' 

j'<'i.n>.siH  Jias  almost  comi.h.f^j     i-  •       ' ''"''  '<^  '«  stated 

--  Imvo  recover.!  po.-.r  in  tl    'a^  ^'''r''^!?'-^-    '^'-^  oti.or  to 
"'"  '•«'')ver  coniplotdv      V,         ,'"'''''  "'"•'•ants  fi.e  belief  tb.    tU 

-.-ivo  ,.o,io-4,,Ht  ^,::;; -'if  ^"  ••' ^^^y..:!^;  :z 

l"''"an.ntly  dan,a,.od.  ""  '""^^'«  g-"l>.s  are  .sure  to  r.uZ 

"-'"^^  to  paraplegia.     SoZul^^'  "'!':''  "--  '"  "4^^ 

^    ^  "■^"^"y  '•«  a  transient  atf  i     1    T     "  '"'''  '^  ■^''S''^  ^'<len>a 
^vitli  the  full  esf-il.i;  I  '  ^^''•^'''  passes  ofl'  i,,  .,  f 

'"  ^■^tahJisliiijoiit  of  ll,..,!,),       !   .  '"  =*  lew  weeks 

a    ase  of  typhoid  fbver  wi(J,  J        )     '^  ^''^'  "'""'''«  ago  I  saw 
«  ""  give  lo  ,l,e  mZ^T::V7  '""■'•'"■'■  "'^  "■•""■on  "l.iel, 


I     ii 


.1 


416 


William  Osier. 


other  forms  of  multiple  neuritis,  so  in  this,  the  outlook  for  complete 
recovery  is  good ;  tiie  histories  I  have  given  show  how  favorable  is 
the  course,  even  in  very  severe  cases. 

In  trcatmcnf  jiersistcnt  massage  is  very  important;  electricity  is  ol 
less  value ;  medicines  are  of  d()ul)tful  utility ;  from  twelve  to  eigh- 
teen months  time  is  the  essential  factor. 


)k  for  coniplotc 
()\v  fiivorabk;  is 

electricity  i~  "f 
twelve  to  eigli- 


"^""'«'*"°'»'*"'»*"«^ff^/. 


^ieporu,  V<,i,  V.7 


^as^^^^m 


CH/LLS  m  TYPHOID  FEVER 


HY 


WILLIAM  OSLEii,  M. 


I). 


WSRSaSKfiaMR 


JOHN   MUKPHY  4  CO.,   I'KINTEKS, 
DALTIMORE. 


JX.— CHILLS  Ii\  TVPrxr^r 

ryPHOlD  FEVER 

BVW,UUAM  OSLER.  M.  D 
In  the  systematic  writers  n.,  f     .    • 
ft»nd  to  chills,  except  I   ;      ^^  '"'  ^^^'^^^  «<^«rce]y  a  rer 
f -V  and  again  'i„  the  In  .aJsT'^""  ^'  ^'^  -*  ^ '     t  eir  " 

fnii        1  \^>'amactom  Vol   ty^  '  -American  Phv 

in-  severe  chilis      n..  '"  af^coiiipa„iod  bv  nill<l  ..    7     ^^^^^'^^^> 

(«)•    -'1/  the  Onset  of  the  n.:. 
^f  /-'  cases  treafprJ   <.>  ,     . 

'.'■'>"  M^dioai,  1892.  "'''^   "'^an  with 


445 


446 


William  Osier. 


shaking  diills.     In  two  cases  thore  were  several  severe  rigors,  in 
three  cases  there  were  two,  while  in  eight  the  rigor  was  single. 

{b).   At  the  Omet  of  the  Relapse.     (Chart  f.) 

Case  I. —Severe  prima rij  ailack;    )io  chill  at  onset;  normal  fcinjHr- 
ature  on  the  forty-first  day ;  apyrexia  for  twenty-three   day.^  ,• 
severe  chills  at  onset  of  relapse  ;  fever  for  forty-two  dayt- ;  apy- 
rexia for  forty-two  days;  second  relapse,  without  chilli,  offowrlcn, 
days  duration.     (Chart  I.) 
Tertia  C.  W.,  aged  22  (?)  (Hos.  No.  8488)  admitted  October  :•  Ith, 
1893,  on  the  seventh  day  of  the  fever.     There  were  no  chills  at  iur. 
onset.     The  fever  was  high  103°-105.5°,  and  she  had  seventy-five 
baths.     The  temperature  fell  to  normal  on  the  forty-first  day.     For 
twenty-three  days  there  was  no  fever.     On  December  -JOth  the  fever 
of  the  first  relapse  began,  and  rose  to  103.5°  by  10  a.  m.  of  the  'ilst, 
when  she  had  the  first  chill,  not  a  severe  one.     At  2  p.  m.  there  \v;is 
a  second  chill,  in  which  the  temi)erature  rose  to  106°.     A  third   one 
occurred  on  the  morning  of  the  2:5d,  and  at  11  a.  m.  the  temperatme 
was  106°.     By  sponging  it  was  reduced  to  normal.     On  the  '24tli  :it 
:!.30  a.  m.  she" had  a  fourth  chill,  in  which  the  temperature  roro  u> 
104°.     The  three  last  chills  were  severe  and  she  sweated  pml'usely 
after  them.     On  the  2oth  there  was  no  chill  ;    on  the  26th  there  wns 
a  slight  chill    at    2  p.  m.     These    five    chills   initiated  a  relap.-e  et 
great  severity,  which  persisted  for  forty-two  days.     There  was  then 
a  period  of  apyrexia  of  six  weeks,  which  was  followed  by  a  second 
relapse  of  two  weeks  duration.     There  was  nothing  in  the  nioilo  of 
onset  of  the  first  relapse  to  account  for  the  development  of  tlie  rliilK. 

Case  U.— Severe  primary  attack;  severe  sincjle  chill  at  onsrl  oj 
relapse. 
Edith  T.,  aged  13,  (Hos.  No.  6487),  admitted  December  24111, 
about  the  end  of  the  second  week  of  a  very  severe  attack.  On  Jan- 
uary 2nd  the  tetuperature  for  the  first  lime  reached  normal,  ami  re- 
mained throughout  the  day  between  98°  and  99°.  On  Janiiuiy  :!r(l 
she  had  a  severe  chill  in  which  tlie  fever  rose  to  105°  and  fell  in  the 
evening  to  99°.  Throughout  the  4th  the  '^Gx^iv  rang<'<l  l.etwwii 
104°  and  105^     On  the  5th  it  fell  to  102°,  and  on  the  'itli  the 


CI >  ills 


'"'*   Ti/phohl  p, 


I'VCt 


vei'L'  I'lgoi's,  111 
,s  single. 

normal  femjjer- 
di/-fh)'et  (l(ij/K  ; 
<ro  (hii/y ;  (tpii- 
hills,  offovrloti 

:1  October  :i  nil, 
no  chills  at  tiic 
ad  seventy-live 
firsi  day.  l''(ir 
■  20th  the  liver 

111.  of  the  'ilst, 

p.  m.  there  \v;is 

A  third   iiiie 

the  teiiiperatuiv 

On  the  24tli  at 
leratnrc^  ro.-i'  to 
'cated  protiiscly 

2Ctli  tliere  was 
:e(l  a  relapse  (jF 
There  was  then 
ved  l)y  a  Heemul 
;  in  tlu!  iiidde  nf 
snt  of  the  eliill-. 

hill   (i(    oiisd  oj 

Deeemiier  'J-ltli, 
ttack.  On  Jan- 
normal,  aiui  I'f- 
L)n  J  an  mil  y  ;!r(l 
°  and  fell  in  the 
ranged  Intuwii 
on  the  ';th  llu' 


447 


niHo 


VIHO 


vim 


vms 


i 


i  "I 


.a  :   m  1 


448 


William  Oalei'. 


temperature  was  normal.  After  three  or  four  days  of  irrcgulai' 
fever,  there  was  continuous  high  fever  from  the  llth  to  the  18th, 
with  rose-spots  and  enlarged  spleen. 

(c).    Chills  an  a  Result  of  Treatmerd. 

Perhaps  the  most  common  cause  of  chills  in  typhoid  fever  is  the 
use  of  medicine,  particularly  antipyretics.  Following  a  dose  of  5  or 
10  grains  of  antipyrin  a  chill  is  not  infrequent.  Last  year  I  saw  in 
consultation  a  patient  who  had  had  chills  for  ten  days  and  had  he- 
come  very  anteuiic.  The  physician  thought  the  chills  were  septic. 
and  was  surprised  when  J  suggested  that  the  antipyrin,  which  had 
been  given  in  full  doses,  was  the  cause.  The  chills  ceased  with  tli,' 
last  dose  of  the  medicine. 

In  one  of  the  following  cases  a  chill  followed  the  injection  t)f  a 
sterilized  culture  of  typhoid  bacilli,  in  two  the  external  application 
of  guiacol. 

Case  III. — iMIl  following  a  lu/podermic  injection  of  sterilized  culluir 
of  typhoid  bacilli. 

Bettie  G.,  aged  27,  (Hos.  No.  8616),  admitted   November  Vlth, 

1893.  The  attack  was  of  moderate  severity.  On  November  lotli, 
17th  and  19th,  there  were  given  injections  of  sterilized  cultures  iif 
typhoid  bacilli.  The  temperature  rose  only  one  or  two  degrees  with- 
out rigor  or  sweating.  On  the  20th,  at  noon,  when  the  temperaturo 
was  102°,  she  was  given  another  injection.  The  temperature  ro.<e 
gradually,  and  at  1.40  p.  m.  she  had  a  chill,  in  which  the  tenii)eni- 
ture  was  105.8°.  It  was  quickly  reduced  by  sponging.  Another 
injection  on  the  23rd  was  not  followed  by  a  chill. 

Case  IV. — Chill  followinc/  the  application  of  guiacol  to  the  skin. 

Evelyn  H.,  aged  24,  (Hos.  No.  9075).  admitted  January  24th, 

1894.  The  temperature  ranged  about  104°,  and  was  very  little  in- 
fluenced by  the  baths.  For  the  first  week  in  hospital  she  was  inurh 
nauseated,  and  vomited  nearly  everything  that  was  given.  On  the 
29th  at  4  p.  m.  guiacol  was  painted  on  the  skin,  as  an  antipyretie, 
and  again  on  the  31st  and  February  1st.  After  one  application  she 
had  a  slight  chill,  and  on   February  1st   nt  xxx  of  guiacol  were 


3  of  irrogular 
to  the  18tli, 


ChiUs  in  Typhoid  Fever. 


\  fever  is  the 
I  dose  of  5  or 
year  T  saw  in 
;  and  had  lic- 
s  were  sei)tii\ 
in,  whioh  had 
ased  with  lli,' 

injeetion  (if  a 
al  applicatimi 

erillzed  culture 

•veiuber  12tii, 
ivember  l")tii, 

3d    CultlUTS   (if 

I  degrees  witli- 
le  temponitui'c 
iperature  ro.-o 
the  tenipora- 
ing.     AnotliiT 

)  the  ski)t. 

January  24tli, 
very  little  iii- 
she  was  imieli 
iven.  On  the 
in  antipyretic, 
pplieation  she 
guiacol  were 


"■  - «i.e h., aw;:;;;;  ;tf' ";■; "> ""U  S nr"3";::rao 

!--« „. .,,,  -i,;:;,;;:;Ti':;»„^"«- -eat.  "e'  r 

'f M-    Po.  .1,0  fi,f.  „,  „t'  f  r,,^";  "■'"•  »"">i«e.l  F„|,„,„,.  .,„, 
•J"  «.e  «i<h,  at  8.30  p.  ,„     h'  I  '''"'•'«'  '™'  '02°  ,?,04  ' 

"I  ™  i>ain,«,  „„  ,L-,;;:;.  ,;';«"-  -  ,03.5-  3 1  J;  Z- 

«■«    7.5»  ami  ,l,e  ,,a,l  „  ,~o  o       i„-,r!,;""'"'f''"l-  '»m™„„,. 
"■I'Klly,  a,„l  by  2  a.  „,.  ,.„„.,,„,  ',;;^'i''  "'"■  »1"<1,  ,1,0  f„.c,.  .„« 

(fl')    Chills  with  the  OnM  of  r.     r     ■ 

.i)"nng  the  height  of  the  fever  or -.fto 

'■;^or  n,ay  precede  the  cleve  Wt  If  ^""^''''^■^-"»«'  ''as  begun,  a 
"^"s,  su,.puratio„  i„  t,,,  ,„esX  ;  ,  J"'^"">»-a,  pleuris/acute 
'-<'"eys,  perforation  of  ile,„„  ^        '    T"'  ''^'^'"'^'  -'>^«^«ses  of  the 

f"  rare  eases   it  n.nv  ,,recede  the    J    ,        "'^' "'"  ■^^''^'^■»«"«  veins 

Vl-Kyrexia.     On  nJ.^^Z.^r''^  «^'  -■^^'  ->•!  fa"/ 

-  .on,s  of  typhoid  fever,  a    w  J   ("'.f"  ":^'  ''^^  '"  ^'-  eon. 

^^l'.ehIhavegivenofour;»«es  ""''*'  '"  ^'^^  ^""  a'mly.is 

In  thrombosis  a  chill  may  oecur  .f  n 
'»ay  be  associate,!  later  n.-tlfsn,,,.    •'"''''  or  r^onrring  .i-^or. 
•''■^■"'•^l-«-.t  of  py.e„.ia.  ^"''''"'•''•^■on  >n  the  clot  and  .vithlL 

^""^^"^^-Severe  chill  mth  onset  of  thr     ,     • 
^  ^  -««■     (Chart  II.)  '^  ''"  ^'''^^-^^^'^  ^/  internal  saphenous 

Theodore  B.,  aeed  •>4  (U      at 
M°-I04».  a,„l  fe^  „„  ,3;,;  ■     «'"    o,npen„„„  ,.a„^,,  „.^  J^' 

»""  '".«l"<e  pain  in  the  ,1, 1' fc    '  """  7''»"»  ™i„  „oc„„.« 
"«',  without  a  chill  to  111'! "  '  "'"'"'"«•     ■  he  tenine™,,,  J 

-  «i ...  .00"  „„;i  1.  f„,;;::;r:';;"-°''»"''™' "-  >eti.,  ,7, 

»  oi  ine  ^2iK(,  when,  at  6.45 


^i 


'H 


H 


450 


WUIinm  OMler. 


a.  in.,  lie  liad  a  severe  fliill,  and  by  8  a.  in.  the  temperature  was  lOo.ri  . 
The  paroxysm  histed  fur  24  hours,  and  was  followed  l)y  heavy  sweat-, 
l-'rom  8  a.  m.  on  the  2;?rd  the  tiMnperatiire  remained  normal  until  thi' 
evening  of  the  2(Jth,  when  tiiere  was  a  r\sv.  to  104.2"  without  a  chill. 
Varolii  this  time  there  was  no  further  fever.  There  was  a  marked 
leucocytosis  at  the  time  of  development  of  the  thrombus  in  the  left 
saphenous  21,200  per  em.  l"\)ur  days  later  the  leucocytes  had  fallen 
to  0,750  per  cm.  Subseiiueutly  the  leucocytes  rose  <luriiig  convalc-- 
ccnee  to  above  10,000  per  cm.,  and  the  patient  beeame  a  little  amomic. 


' 

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£Ar     £S     £t    21    £6     Z3     JO    Jl     JZ  JJ    JV    JS    Ji    J7 

(JiiAur  II.— Cliill  (It  Onset  oj  ThromhoB't. 


, 


CA.sr<:  VII. — Severe  attach  of  fever;  thrnmhoKiH  of  the  femoral  trin; 
eight  days  later  a  severe  r'ajor. 
September  23rd,  1895. — While  makini!;  rounds  in  Ward  I',  my 
attention  was  called  to  the  patient  in  Bed  18,  whom  we  fouiul  in  ii 
severe  rigor.  He  had  been  very  ill  for  ten  days.  On  the  1-Jili  ()i 
September  a  thrombus  had  developed  in  the  left  femoral  vein,  and 
the  loot  and  leg  were  swollen.  He  had  a  very  dry  tongue  ami  wa.s 
delirious.  This  morning  at  8  a.  m.  the  temperature  was  102  .  At 
ten  o'clock  the  eliill  began,  and  he  shook  for  twenty-five  iniiiiito^. 
The  temperature  rose  during  the"  paroxysm  to  105°.  He  wa- vm- 
cold  and  blue  during  the  ehill,  but  half  an  hour  later,  when  1  lit  the 
ward,  he  was  feeling  very  eomfortable.     No  further  chills  (ncmi'ed, 


rt>  was  1()5..">  . 
licavy  Mwrats, 
•inal  until  the 
itiioiit  a  chill. 
van  a  maikr,| 
us  in  tiu>  left 
'tcs  had  (iiiliii 


^'-'"■/^•v/.    T;,i,hni,,   /,',,,^. 


('A.SJ.;  vjir. 


-.Ir//, 


P.i/re.i'i, 


WUil 


f'li'l  daith. 


<      U  NCI 


•ire  I 


'Hl'»- JnUnwrd  I, 


I'foiirliiiin 


Kllfj 


I'-S/flll 


''//  <:i/'nto.v's,  /, 


•illlU!  Ml    to(( 

"1  a  state  of  j 


'\  '-^^-i^i-.^  tins  pa,,,,,  s< 


""'"'at  a, .rival 


'ptcml), 


''•  ^'«t,   JS05. 


J)i 


Tl; 


'ypoi'pyrcxii,.  aft 


'''"""'"""  ^^'anlCl.a.l.i;,.,, 


'Ujirr- 


aisuii). 


•  Vboiit  A 


''^'   paticiil,   \\\   \v 


<'i'  a  .s(j\-( TO  I 


i^'or. 


■^iiddoiil, 


".f^t]5,),,  a,  (,,,,„„  ( 


'-"•'    I".   Has   adM.im.l 


'"'"  '"ise,-al.lo.     Tl.inI, 


>"y:  tliat  tli( 


'"y,  lie  first  I 


■■^•■pl'inlxT    J  |(j, 


iiiuci 


!i  \V()rs(. 


vuiiiitcd 


Til 


ig<'  '^iiiiiniit. 


sea    did 


''t-  ,irastri(r  ,sv 


Alioiit  .Sept, 


almost    cvorvd 


iiipton 


na  were   vci-v 


"'^""  '"  '<^"l   wivtcluHl 
■"iIxT  I,st|„,| 


; •■■-  "n„„r;,::n  1,  ::.,:::"^-  ".:^».i. 


'Ji'.ii'i'avatci 


"■(•aiiic  vcrv 


iiiiil 


lia.s  tal, 


'^«'"  very  larjre  do.se.s  of 


'(■adaclic  and 


»''■"   trcai,,!   / 


"""'''••ate,  not  i^ad 


Mi'i'iinc.     Tlio  t 


'  ^:''  ''«•"'  of  p,,,s,,at 


nr 


'"u,  an( 


V( 


'••V' Jivid  and  l)hu- aft 


'"'•f^lO^^-     HcMoolcIuir '■'•'■ '!^«- 


iniicl)  I 

in 

,1 


■rtl 


tlif  l)atl 


\vas 


'IS   vci-v  I 


"'■'>n,.|,itis  tl.at  it  was  tl, 


pnJ.se 


";'"' ••'";!  "n8c.ptend,e,-]Dtl, 


-adly,  w 


IS 


="if'y  a  .sntfused, 


\va.s  good  and  t\n>  \ 


"'ii,i,dit  l)(.tt( 


onien  w 


I)  woinewliat 


""ift  sonnds  el 


'■'  f'>  sidjstitute  tl 


,  tlicie  wa.s  so 


ll.sliv 


!oai- 


l)Mt 


pOMirc; 


■'^  distended  and  sort.  "  Tl 


"PP«ii-ance  of  (|,(,  | 


li.id 


''"'*;'  ='  ''^^^^^I>iginenk.,l 


"t'i'e  were  no  ,.|, 


iU'c, 


araetei'ist 


con- 
'Ih'  ab- 


I,,     .li-  ,  "^iwi  \  .  I  J,,    1......    „, 


If    !• 


)>e- 


hiiiise 


On  S, 


''^.andonSepfeinl 


'pten)ber  20tl 


Vy?r ''^''"^^'^■'^'y  ^'•igl'tened' 


's  ni.iitai 


'^'''  '7(b  ami  I8tl,  tried 


ahont 


li  and  21st  I; 


'  g't  ont  of  Ih.,i. 


;:7'-;<tnre  bad  not  been  \ZC ^.  T"'"'":^  """'■"'"'^  '«'"e 
foity-e/glit  Ii 


',irli,  tlie 


iilliiniiin  in   th, 


loiirs  not  above  ]  0,3 


'Uoi'ninj: 


^  '>»""ie,  and  a  fe 


'i^J 


and 


I  <'!■<'  was  a 


"■:'-™--' *.in„:,.'-~r„'r' 


The 

evening  reeord  foi^ 

slight   traee  of 


lai  at  half 

ijcttcr, 


■I)a,st  el 


iind  I  ordered  t\ 


",■^•7   <"'   S<-pten,ber   21st      Tl 


poratnre  was  102.5'= 


'le  bati 


visi 


it  lie  was 


at  10 


's  to  be  re- 


'le 
'le   I 


ine  easts 
''<in. 


I 


saw 


nnied.     Tij 


sweating  profu,soly,b„;,„ 


;'•"'•  '^  '''"I  n-.sen  to  104.3 


>''<'iichitis   u-as 
't'  morning  teni- 


le  seemed  better  and 


At  th 
was  rational. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


1.25 


■  50     '""== 


2.5 


22 

^    1^    liP-0 


U    lllll  1.6 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


iV 


^^ 


..<*. 


'^^ 


■\ 


452 


William  Osier, 


He  had  ta.veii  his  nourishment  very  well.  At  one  o'clock  he  had  a 
very  severe  chill,  shaking  violently.  The  respirations  were  hurried 
with  loud  expiratory  blowing.  The  expression  of  the  face  was  tluu 
of  fright,  and  he  constantly  talked  of  someone  trying  to  kill  him,  and 
called  out  for  help.  The  pupils  were  widely  dilated  and  equal ;  Ik; 
sweated  profusely.  At  noon  the  temperature  was  104.2° ;  at  1.45  p.  n:. 
it  had  risen  to  106.2°.  At  this  time  the  chill  had  almost  disappeared. 
He  had  become,  however,  quite  cyanosed,  the  hands  purple,  the  lips 
blue  and  the  face  very  dusky;  the  pulse  could  scarcely  be  felt.  There 
was  from  this  time  slight  twitching  of  the  left  side  of  the  face,  but 
no  regular  convulsion.  The  cyanosis  be(;ame  more  marked,  and  he 
became  progressively  weaker.  The  temperature  rose  to  107.5°  at  2 
p.  m.,  the  highi.st  recorded  temperature  in  any  case  in  typhoid  fever 
treated  in  the  Hospital.     He  died  at  2.45  p.  m. 

(e).    Chills  {septic  /)  during  convalescence  in  severe  and  protracted  cases. 

In  a  few  instances  rigors  occur  throughout  the  course  of  the  fever, 
without  any  local  symptoms  to  account  for  them.  Tiie  followin^r 
cases  are  of  great  interest  in  as  much  as  the  chills  were  not  associated, 
so  far  as  could  be  ascertained,  with  any  complication,  and,  thoiiL'li 
very  aiurming,  they  gradually  subsided  with  complete  recovery  of 
both  patients. 

Case  IX. — Severe  and  protracted  fever  ,•  in  the  seventh  and  eii/lith 
week  of  illness  recarrinr/  chills  with  hie/her  fever;  no  local  si(/ns  ,- 
recover  I/.     (Chart  HI.) 

Thomas  W.  T.,  aged  36,  (Hos.  No.  8667),  admitted  Novoiiiher 
21st,  1893,  on  about  the  eighth  day  of  the  fever.  The  teniper;itiire 
range  was  high  and  the  constitutional  symptoms  severe.  Fie  was 
given  during  the  first  week  injections  of  sterile  cultures  of  ty[)lioid 
bacilli  in  thymus  gland  bouillon,  without  any  influence.  !  )n  \o- 
veniber  2.Stli  an  injection  was  given  at  2  p.  m.  The  temperaMn-e  did 
not  rise  more  than  a  degree.  At  12  midnight  he  had  a  shaking  eliill 
of  twenty  minutes  duration,  followed  by  profuse  sweating.  The  in- 
jections were  omitted  and  he  was  ordered  baths.  He  had  audthci' 
chill  on  the  30th  at  6  a.  m.  The  temperature  rose  to  105°.  The 
j)atient  did  well  with  the  baths  and  sponges,  though  he  had  delin'iiii) 


\\ 


'clock  he  had  i 
s  were  hurried 
le  face  was  tin  t 
to  kill  him,  and 

and  equal ;  lie 
1°;  at  1.45  p.n). 
3st  disappeared, 
purple,  the  lips 

be  felt.  There, 
if  the  face,  Liit 
narked,  and  lie 

to  107.5°  at  2 
1  typhoid  fever 


irotracted  cusck. 

'ie  of  the  fc\(^r, 

The  following.' 

not  associated, 

II,  and,  thoiiL'li 

9te  recovery  nf 


nth  and  ejijhih 
110  local  ,si(/n.i ; 

ted  Novenil)er 
le  teinpe'ratiin' 
vere.  Fie  wa^ 
res  of  ty{)li()i(l 
ncc.  On  No- 
>nipera*i;re  diil 
11  shakiiiti:  ''''ill 
ting.  The  iii- 
e  had  anDthcr 
io  105°.  Tlio 
e  had  delirium 


Chil/s 


in 


^>/p/ioid  Fev, 


ev. 


463 


:1m 


454 


Wit/ium  (Mcr. 


irenior,  II  dry  tongue  and  a  slightly  distended  abdomen.  On  W- 
ceinher  lltli  tlie  temperature  rose  to  103.5°  and  he  had  a  spon-v 
bath  after  whi.'li  he  had  a  chill.  1'hen,  about  the  Ibrty-Jourtli  dnv 
of  the  illness  tlie  temperature  reaehed  normal.  He  had  been  verv  ill 
and  had  a  sligiit  phlebitis  of  the  long  saphenous  vein.  From  the 
J3th  to  the  2<Sth  ol'  December  he  had  an  irregular  fever,  toucliii,:^ 
normal,  or  99°  each  day  and  rising  to  103°  or  101°.  On  the  25tli 
with  t!  is  ri.H'  he  had  a  profuse  sweating,  on  other  days  the  sweats 
were  less  marked.  As  the  fever  subsided  he  looked  much  emaeiatnl 
and  the  abdomen  was  seajiboid.  There  was  no  diarrhroa,  and  he  had 
a  good  appetite. 

On  December  29th-31st  there  was  irregular  fever,  but  low(n'  llian 
before,  and  it  seemed  as  if  convalescence  had  begun.  Though  he  IMi 
well,  the  general  condition  was  not  very  favorable:  he  had  two, 
sometimes  three,  soft  movements  daily ;  the  pidse  ranged  from  90° 
to  108°,  and  he  had  become  very  much  emaciated.  During  the  liist 
ten  days  of  January  he  had  a  series  of  severe  chills.  The  ten\pera- 
tnre  rose  to  103.5°  and  105°,  and  in  the  intervals  was  normal  or 
sub-normal.  There  were  .seven  chills  diu'inf  '  -  ten  days.  The 
paroxysms  lasted  from  twelve  to  fifteen  hours 

The  most  careful  examination  faileil  to  show  any  local  lesion.-  m 
account  for  the  chills.  The  examination  of  the  blood  was  negative. 
There  was  a  systolic  murmur  at  the  l)ase.  The  spleen  was  still 
palpal)le.  After  January  14th  the  temperature  remained  normal. 
The  recovery  was  slow  on  account  of  the  great  wasting.  On  sitting 
up  Fel)ruary  1st,  he  weighed  I'V^  pjunds;  on  March  3rd  he  wciglud 
143  pounds,  and  at  the  time  of  his  discharge,  March  15th,  marlv 
150  pounds. 

Cask  X. — Altnck  of  vioderate  Hvveritij;  in  the  oth,  Gth,  7fli  wnl  v/// 
wech  cliil/n  of  (/rent  Intensity  ;  recovery.     (Chart  IV.) 

November  6th,  ■'894,  I  saw  at  Charlottesville,  with  Dr.  Hugh  T. 
Nelson — V.  S.,  aged  about  20,  a  stu  lent,  who  had  been  ill  with  liver 
since  October  1st.  He  had  come  from  Charleston,  September  lotli, 
and  shortly  before,  while  shooting,  had  been  exposed  in  a  very 
unhealthy  region.  The  attack  was  one  of  moderate  severity  ;  the 
temperature  ranged  between  104°  and  105°,  without  many  snioii^ 
symptoms;  but  in  the  fourth  and  fifth  weeks  liis  temperature  did  imt 


""■""  '"    I'll'l'okl  Fear. 


ilwlinc.    On  Novenibci-  J,,  „,   i    ,  ^''^ 

i;i;.:;n;r,rv''^'««'''»'"*":tr:,"!^'™r: - 

>:,.)  '    '"^^^'"-'"^    tOtKtT,    no    ^tmf.        •'•.  ,  ''"'''"'It'll   \V;,s  i, 

fi".^ors  breaclU.    beJow  the  amWe     f  L      ''    "'"^   '^'^^"^'^  ^o  thro" 

-p..  ar  region  tl.ere  u-as  foel.Jo  ,    "  ,    ''  "''"^r""-     ^^^•--  the  inf,, 

^«"-   ^"e,  craoklin.  rales    -u.  \'^' '"''""  ^'^<^P  i'>.^pir,tio 
Tiw.   1       .  '^   I'litS),  and   tile  t'i#.til,>  ^       •  ^  '"■'firation  a 

.p  "  '"■"'■'  »"»*  wee  dear.    T|,l ,        "'"""""'  ™»  ''".■.•msl.e.l 

""■""■■"•.'olW^  media.  ""   "■"■'   ""  l'"»   .-..   the  „,.iro 

.»-Ue,,,;ea,,„fc  ,„,,„,,,,  '°f         '';«'op.-otol,le , hat  the  c»,se  wL 
"f  eo»e  isasf„,i.„v,..     Rotter ',?■'■,    ''"'"  •™''«<l"<=n.  c  ,  7* 

'"Vl-fVon,  99of,    J:  r-^-^  ^''^>  temperature  range  was    ot  o    , 

"^03.  Fronuhe  20th  to  the  2itht,:: ;::;;::,:: 


f. ) 


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456 


William  Osier. 


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J^^ato  r.,  aged  31  (Hos  No  1l'?-^i\      i    • 

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0^ 


THK  PKACTICAL  VALUE  OF  LAVHRAN'S 
DISCOVERIHS. 


BY 


WILLIAM   OSLER,  M.D., 

OF  IIALIIMOUR.  Ml).: 
PHOFKSSOR    OP    MBI.IC1NE,   J,„1NS    HOPKINS   UNUHKSITV. 


FROM        » 

THE     MEDICAL     NEWS, 
November  33,  1895 


ill 


IKn'rintedfmmTll..;  MK..I.AI.  \f.\vs,  N„v„n,,„, 


f  2.<.    1895.1 


THE    PRACTICAL     VALUE    OFLAVERAN    S 
DISCOVERIES.' 

Bv  VVIM.IAM  OSLER,  M.n., 

Ill*  IIAI.riMrinr!.  Mil  , 


PBOFESSOH    Ol'    .M 


■"">M:.    In.lNS   II.M'KINS   IMVKHM  |  V. 


Even  m  well-known  affections  advances  are  made 
from  t.me  to  fme  that  render  necessary  a  revi   on 

old°nlv"""""''^  ^""^'^'^'^-  ^  ^-djustHK-nt  of 
old  posu.ons,  a  removal  even  of  the  old  landmarks 
Perhaps  the  most  ren,arkable  illustration  of  this 
offered  by  the  discovery  of  the    tubercle-bacilu 

before  i88r  !     Happy  those  who  had  agility  and  wit 
sumc.ent   for    the    somersault!    Scarcely 'ess   im 
portant  has  been  the  revolution  in  our  knowledge  of 
malar.a  s.nce  the  researches  of  Laverar.,  in  iSS ',  on 
he  paras.te  o   the  disease.     His  discoverv  attracted 
for    a    tmie   little    ^Uention,  chiefly   because   the 
workers  m  patholo    .    ^he  world  over,  had  not  op- 
portunuies  for  studying  the  disease.     The  verifica- 
tion of  his  work  came  slowly,  while  the  conception 
fr       .rrr    "^  consequences  has  not  yet  filtered 
trom  the  laboratories  and  clinics  into  the  wide  field 
of  every-day  practical  medicine. 
.Z^^'^  ^--e  several  aspects    in    which   Laveran's 
studies  may  be  considered  as  of  immense  value  ; 

THE     RELATION     OF    THE     PROTOZOA     TO    THE    ACLriE 
INIECTIONS. 

A  Stimulus  has  been  given  to  research  that  has 
already  borne  fruit   in  observations  upon  amebic 

dysentery  Texas  cattle-fever,  and  certain  skin-affec- 
tions.     The  question  of  the  protozoal  origin  of  car- 
cinoma has  been  revived,  and  prosecuted  with  an 
'  Read  before  the  Medical  Society  oTthe  Distn^oTcolu^ 


energy  that  must  result  in  a  valuable  addition  to 
our  knowledge  of  the  structure,  and  ])ossil)ly,  too, 
of  the  etiology  of  malignant  growths.  Althougii 
the  life  history  of  the  ])arasite  is  as  yet  imperfectly 
known,  sufficient  details  arc  ivailable  to  furnish  one 
of  the  most  interesting  chapters  in  pathology,  and 
at  last  we  have  revealed  the  meaning  of  that  peri- 
odicity, SI)  mysterious  a  feature  in  the  malarial  fevers, 
which  has  puz/.led  generations  of  physicians  since 
Hijjpocrates.  As  a  direct  outcome  of  the  study  of 
the  protozoal  jiarasites  of  |)aludism  may  be  men- 
tioned the  really  brilliant  discovery  by  Theobald 
Smith  of  the  i)arasite  of  Texas  fever,  also  a  hema- 
tozoon,  connected  in  its  life-history  with  the  cattle- 
tick  (Boui)hilus  bovis).  Xo  more  interesting  prob- 
lem in  com])arative  i)athology  has  been  solved  of 
late  years,  and  the  life-history  of  the  parasite  is 
better  known  than  that  of  any  other  path(;genir 
protozoon. 

IIIK    liIACNOSlS    Ol'    MAI.AUIA!     IKVKK. 

The  best  guarantee  of  a  truth,  xi  some  one  has 
said,  is  the  wisest  men's  acceptance  of  it.  There 
has  been  an  extraordinary  unanimity  in  the  verifica- 
tion of  Leveran's  main  facts  by  every  competent 
worker  who  has  had  suitable  opportunities  for  the 
study.  The  extensive  and  complete  bibliography-- 
the  most  complete  yet  published — in  the  mono- 
graph by  my  assistants,  Drs.Thayer  and  Hewetson,' 
gives  some  idea  of  the  widespread  interest  which 
the  question  has  aroused.  It  is  not  too  much  to 
say  that  Laveraii's  work  has  revolutionized  the  study 
of  fevers,  as  now  a  trained  observer  can  deter- 
mine whether  any  given  case  of  fever  depends  upon 
a  malarial  infection.  The  parasites  are  present  in 
all  forms  of  the  disease,  and  constitute  a  diagnostic 
criterion  of  unfailing  accuracy  in  uncinchonized 
subjects.  A  certain  technic  and  training  are  re- 
quired, which  a  season  in   any  malarial  center  can 

'  "  The  Miliaria!  P'evers  of  Baltimore."     Johns  Hopkins  Hos- 
pital Reports,  1895.  Vol.  V. 


ties  I  shall  refershortly  to  theexiraordinarv  ahi.se 
of  the  term  n.alaria,  whi.:h  is  used  as  a  cloak  to 
cover  our  ignora.u  eof  the  nature  of  ob.cure  fever 
A  more  extended  knowledge  of  the  fart  that  the 
ma  arjal  fevers  are  readily  and  qui,  kly  recr.Kni.ahle 
w.ll  Kive  the  physician  pattse  in  a  hasty  ditgno 
and  wll  ,n  fme  obviate  one  of  the  most  «lar  . 
maj:^^urac,e.   in    the   mortuary   returns    of    cer.ain 

Hut  it  is  in  the  study  of  the  fevers  in  the  tropics 
thatLaverans  discovery  will  prove  of  the  ..rcaiest 
serv.ce,    and   as   shown  by  the  work  of  N^,„dyk 
Carter,  .n  India,  and  Dock,  in  Galveston,  the  dilL 
enfation  of  malarial  from   other  fevers    is  n„ickiy 
made.     It  ,s  nu.st  important  that  men  who  desire 
to  study  this  problem  should  be  equinoed  with  the 
necessary  technic.     Several  recent  reports  on  ma- 
laria  ,n  the  tropics  have  been  sadly  defective,  and 
show  that  valuable  opportunities  h.ve  been  wasted 
from  lack  of  proper  training  on  the  part  of  the  ob- 
server     Accurate  information    on   the   subject,   in 
iMiglish,  has  not  been  until  recently  available      Mv 
article  in  the  Brithh  Mciical  Journal  (,887  "l) 
remained  for  several  years  the  only  one  which  had 
a  wide  circulation,  and  the   letters  which   I   have 
received  from  i.ractitioners  in  distant  parts  of  the 
world  indicate  that,  with  the  imperfect  literature 
there  coexisted  as  a  rule  imperfect    training  and 
faulty  apparatus.     Now.   however,   the   publication 
by  the  New  Sydenham  Society  of  Laveran's  mono- 
graph,  and  of  the  works  of  Marchiafava  and  Big- 
nami  of  iMannaberg,  and  the  monograph  of  Thayer 
and  Hewetson.  already  referred   to,  gives  access  to 
all  the  ava.'a'ie  literature,  and  should  prove  a  great 
stimulus  to  the  study  of  tropical  fevers  from  the  new 
standpoint. 

For  so  many  generations  the  paroxysm  of  inter- 
mittent fever  has  stood  for  the  type  and  representa- 
tive o  the  class  of  fevers  associated  with  chill  that 
It  has  been,  and  still  is,  very  difficult,  particularly  in 


;i.   ' 


this  latitude,  to  avoid  the  suspicion  of  paludism  ''n 
any  disease  associated   with  recurring  rigors  ;  and 
yet  one  may  safely  say  that,  in   the"  cities  of  the 
Atlantic  seaboard,  the  instances  of  chills  and  fever 
due  to  the  malarial  parasite  are  greatly  exceeded  by 
those  of  various  other  affections.     The  idea  seems 
firmly  ingrained  in  the  mind,  and  I  scarcely  pass  a 
week  without  seeing  some  instances  in  which   the 
diagnosis  of  malaria  has  been  made,  simply  because 
the  patient  has    had    recurrent  chills.     The  error 
would  not  be  so  unfortunate  were  it  not  for  the  fact 
that  it  often  causes  delay  in  the  adoption  of  suitable 
treatment,  and  may  completely  blind  the  physician 
to  the  true  nature  of  the  case.     Perhaps  the  most 
frequent  mistake  is  in  the  chills  and  fever  of  tuber- 
culosis.    As  is  well  known,  these  occur  at  the  two 
extremes  of  the  disease.     It  is  more  particularly  in 
the  <  arly  stages  that  the  mistake  is   serious,  and  I 
have  on  many  occasions  known  a  patient  treated  per- 
sistently for  malarial  fever  without  a  suspicion  hav- 
ing arisen  Lhat  the  trouble  depended  upon  tubercu- 
losis.    In  all  vaiicties  of  septicemia  the  mistake  is 
most  frequent.     Malaria  postpartum,  of  which  one 
hears  not  a  little,  is  very  often  septicemia,  and  I 
rarely  see  a  case  of  abscess  of  the  liver  that  has  not 
been  drenched  with  quinin,  in  some  instances  for 
months,  in  the  belief  that  it  was  a  chronic  malaria. 
Frequently  pyelitis,  pyelonephritis,  gall-stones,  and 
empyema  are   in  the  same  way  overlooked,   and, 
even  when  the  diagnosis  has  been  demonstrated,  I 
have  often  heard  from  physicians  expressions  which 
indicated  a  lingering  idea  that  after  all  the  septic 
trouble  was  only  a  consequence  or  a  complication. 
The  profession  at  large  has  not  yet  laid  to  heart 
the  following  rules : 

1.  That  the  diagnosis  of  the  malarial  fevers  can  be 
made  with  certainty  by  the  llood-examinatton. 

2.  That  an  intermittent  fever  which  resists  quinin 
is  not  of  malarial  origin. 

A  rich  experience  during   the   past   nine   years 

warrants  the  expression  of  these  positive  statements. 


In  the  differentiation  of  the  fevers  of  the  South 
about  wh>ch  so  niuch  discussion  has  taken  p  a  e 
dunng  the  past  ten  years,  the  study  of  the  chan  s  n 
he  blood  must  ,n  the  future  play  a  n.ost  impor  " 
role.  1  he  question  of  the  existence  of  a  thi  d  type 
of  continued  fever,  which  has  been  advo  ated  v 
Guireras,  Baumgarten,  and  others,  cannot  te  de- 
term.ned  without  a  mo  omplete  study  than  has 
yet  been  given  to  the  cases, 

When  one  reads  the  report  of  the  Proceedings  of 
the  Orleans  Parish  Medical  Society,  in  whi    ff°r 
many  years  the  nature  of  the  long-continued  L 
of  Louisiana    has    been   discussed,   the   condition 
eally  seems  to  be  similar  to  that  in  which  the  pro- 
fession labored  before  the  differentiation   of  ty,S  us 
and  typhoid  fever.     It  is  interesting  to  notet£t  i 
New  Orleans  at  least  physicians  seem  to  be  comin " 
gradually  to  the  conviction  that  the  long-continued 
fever  which  resists  quinin  is    in  reality  typhoid    a 
view  strongly  advocated  by  Dr.  Matas  in  a    hi.t 
paper, n  r.n.:  Mei.k;.m.  Nkws  of  December  ,5,  X894 

M.M.AKIA    AND    VITAL    STATISTICS. 

•  '^'!f  ^:'-  f"  '^^^"'"'  '^^•'°'''  f""-  1890,  recently 
issued,  which  covers  the  six  years  ending  May  ^ 

1890,  gives  the  following  number  of  deaths  from 
malaria,  to  which  I  add  for  comparison  those  of 
typhoid  fever .- 

n^!^Tr''^f^'^T-  5-=  Typhoid  fever,  850. 
New  York-  •■  <■      3;';,^;         „  l'         9°4 

Brooklyn-  •'  ",,,..  .,  „        -°^^ 

'-t'j'  1002 

That  in  Baltimore,  New  \'ork,  and  Brooklyn  the 
dea  hs  from  malarial  fever  exceeded  those  from 
typhoid  will  no  doubt,  be  read  with  astonishment, 
particularly  by  those  familiar  with  the  conditions  of 
practice  in  those  cities.  Any  reasonable  physician 
m  ]  hiladelphia  or  Baltimore  will  at  once  acknowl- 
edge that  a  death  from  malarial  fever  is  a  great 
rarity,  while  deaths  from  typhoid  fever  are  only  too 


common.  Taking  the  reports  of  the  large  New  York 
hospitals  as  a  basis,  one  can  estimate  the  degree  of 
reliability  of  the  figures  on  which  the  mortuary  sta- 
tistics are  prepared.  In  the  last-issued  report  of  the 
Department  of  Public  Charities  and  Correction  of 
New  York  (1894)  for  the  year  1891,  the  compara- 
tive rarity  of  malarial  fever  is  well  indicated  by  the 
fact  that,  of  above  15,000  patients  admitted  to 
Bellevue  Hospital  during  the  year,  there  were  only 
15  instances  of  intermittent  malarial  fever.  It  is 
true  that  there  were  76  cases  of  typhomalarial  fever 
and  only  16  of  typhoid  in  the  figures,  which  is  sur- 
prising, considering  the  little  stress  that  has  been 
laid  of  late  years  upon  typhomalarial  fever ;  but 
when  one  turns  to  the  list  of  deaths  and  finds  that 
all  the  cases  of  typhoid  fever  died,  16  in  number,  it 
looks  as  if  the  diagnosis  rested  a  good  deal  upon 
whether  the  patient  recovered  or  not.  In  the  total 
number  of  deaths,  1547,  malaria  does  not  appear  as 
accounting  for  a  single  one.  So  also  at  the  Charity 
Hospital,  of  619  deaths  not  one  was  caused  by 
malaria. 

At  the  Roosevelt  Hospital  in  the  year  1893  there 
'.vere  treated  in  the  medical  division  1436  cases,  and, 
so  far  as  one  can  gather  from  the  report,  there  does 
not  appear  to  have  been  a  single  case  of  malaria 
treated  in  the  wards.  Br.  Roosevelt,  to  whom  I 
wrote  on  the  subject,  kindly  informs  me  that  from 
January  i,  1883,  to  December  31,  1893.  inclusive, 
there  have  been  but  two  deaths  from  malaria,  both 
cases  of  the  pernicious  form.  The  total  number  of 
deaths  in  medical  !:,ases  during  this  period  was 
2024,  so  that  the  proportion  of  deaths  from  malaria 
to  all  deaths  from  disease  in  the  medical  division  of 
that  hospital  during  the  11  years  was  about  i  to 
1000. 

In  the  New  York  Hospital,  for  1893,  of  1482 
medical  cases,  there  were  in  all  38  cases  of  malaria, 
with  one  death  from  pernicious  fever. 

Through  the  kindness  of  Dr.  Browning  I  am  able 
to  give  more  extended  figures  for  Brooklyn,  a  city 


7 

in  which  the  prevalence  of  mahrin  h. 
attention  of  the   profession   ?n  ""'^^^'^  '^^ 

figures  and  tables  s  n  to  1  ^  """'  '''''■  ''''' 
direction  of  the  Col  itt  o  He'.^r"?^  ''" 
supervision  of  the  secretar     D     "^^^:':sf^f 

havedin:inii::d\;tt7:::;;;;'U'^'"^'r'"^^'-- 

one-half,    the    tvLhoiH    ll       I         "  ^°  '"^  ^'^^n 
During  the  same  nerioH  U      '  ^r    '""^  ^""l^'^d. 

fully  oL-harin       y  a    i^ri" '^tnM  '"-^  '"^^^^^^^ 
the  city's  area      Fv^n  '\'"'^'' ^^'^''"  l^y  nicrease  in 

inc,  Jed  r„..^-:tv  :^x;»,,x  .'■.'- 

figures   and  tl,    '^'l^^^^iscrepancy  between  these 

lows,  Typhoid  frvef.V,,'^'""?  "' "=  f"'" 
TT^.  J       T  '      ^^'  typ'ioma  arial    fevpr 

"04 ;  and  malarial  diseases,  2006     In  the  Tr.        ' 

.ha.  il™i„7„  r::;„,T ed  iJ'  ""  -^»°«'>'^«i 

rif;iri:f""^--=^:^'is 


•  N.  Y.  .Nf.,|,  journ.,  18 


I 


II 


I 

<  iiii 


il 


8 


do  I  see  one  mentioned  in  the  discussion  following 
the  reading  of  the  reports.  In  September,  1893, 
the  members  of  the  Society  of  the  County  of  Kings 
again  discussed  at  length  the  ([uestion  of  malaria  in 
Brooklyn.'  I  have  looked  carefully  through  all  of 
the  papers  there  read,  and  it  is  certainly  a  very 
significant  fact  that  not  one  of  the  authors  of  the 
papers,  and  not  a  physician  who  discussed  the  ques- 
tion raised,  mentioned  the  occurrence  of  fatal  forms 
of  malarial  fever.  In  the  article  by  Dr.  Hall  on 
types  of  malaria  seen  in  Brooklyn,  in  which  he  quotas 
the  observations  of  a  number  of  physicians,  no 
mention  is  made  by  any  of  them  of  fatal  forms,  and 
this  is  a  city  credited  in  the  bills  of  mortality  with 
as  many  deaths  from  malaria  as  from  typhoid  fever  ! 
Certain  of  the  writers  of  the  papers  seem  to  have 
themselves  been  a  little  suspicious;  thus  Dr.  Hall  re- 
marks that  "  Carelessness  of  diagnosis  probably 
affects  our  ideas  of  the  prevalence  of  malaria  to  a 
considerable  extent;"  and  Dr.  Law,  in  the  methods 
of  treatment  of  malaria  in  Brooklyn,  states  that  it 
seems  to  him  a  good  practice  in  cases  of  the  remit- 
tent type  of  the  disease  to  give  quiniri  in  large  doses 
for  two  or  three  days,  and  then,  if  the  fever  is  not 
broken  up,  to  stop  and  take  bearings  and  search 
for  some  inflammatory  lesions,  or  reconsider  the 
possibility  of  typhoid. 

The  report  from  the  Brooklyn  Hospital  gives  the 
following  :  In  1S90,  of  608  medical  cases  admitted 
there  were  18  cases  of  ma'aria  and  no  deaths.  In 
1S92,  of  742  medical  cases  admitted  there  were  27 
cases  of  malaria  and  one  death.  In  1893,  of  6S3 
medical  cases  admitted  there  were  20  cases  of  ma- 
laria and  no  deaths. 

In  the  report  from  the  Kings  County  Hospital  for 
tiie  year  1892  there  were  no  deaths  from  malarial 
fever  in  a  total  of  nearly  3000  patients  treated  with 
310  deaths.     In  the  rejiort  for  the  year  ending  July 

'  Brooklyn  Med.  Journ.,  Jan.  1893. 


31,  1893.  there  was  one  death  from  pernicious  ma- 
larial fever  in  a  total  of  3258  patients  treated,  with 
425  deaths. 

In  dealing  with  the  statistics  of  malaria,  Brooklyn 
may  be  taken  as  a  model,  and  I  have  dealt  with  it 
part  y  because  of  the  reputed  large  death-rate,  and 
part^iy  because  the  activity  of  the  members  of  the 
Medical  Society  of  the  County  of  Kings  has  fur- 
nished most  su^rgestive  material,  which  has  been 
supplemented  by  the  kindness  and  energy  of  Dr 
Browning. 

In   localities  frequented  by  the  disease,  malarial 
fever  kills  in  such  a  way  that  the  diagnosis  is  rarely 
m  doubt.     In  the  acute  cases  death  follows  within 
a  few  days.     In  other  cases  the  hemorrhagic  features 
prevail,  while  the  malarial  cachexia  or  the  acute 
exacerbations  in  the  malarial  cachexia  less  frequently 
prove  fatal.     The  simple  intermittents  rarely  kill 
even  when  protracted.     Taking  into  consideration 
the  statements  of  physicians  in  Brooklyn  and  Long 
Island,  as  given  in  the  reports  referred  to,  together 
with  the  striking  absence  of  all  reference  to  fatal 
forms,  also  the  distinctive  and   readily  recognized 
character  of  the  fatal  forms  of  malaria,  one  cannot 
help  feeling  that  in  these  localities  and  elsewhere  the 
diagnosis  is  put  down  carelessly,  and  does  not  repre- 
sent in  any  way  the  incidence  of  malarial  fevers.     In 
the  oft-quoted  and  oft-printed  chart  of  the  Michigan 
State  Board  of  Health,  showing   the   comparative 
mortality   from  typhoid   fever  in  sewered  and  un- 
sewered  toi"ns,  Brooklyn  figures  almost  at  the  bot- 
tom of  the  list,  having  a  mortality  of  1.5  per  10,000 
mhabitants,  a  mortality  which  is  much  more  than 
doubled  if  we  add,  as  it  seems  should  be  done,  the 
deaths  due  to  typhomalarial  fever  and  those  due  to 
malarial  diseases. 

The  conclusion  of  the  whole  matter  may  be  thus 
briefly  expressed— the  mortuary  bills  dealing  with 
malaria  are  false,  due  either  to  ignorance  or  to  wil- 
ful deception  on  the  part  of  those  who  make  the  re- 
turns.    Malaria  is  a  disease  that  now  rarely  kills  in 


!  V 


if 


10 

the  large  towns  on  the  Atlantic  seaboard,  and  it  be- 
hooves the  profession  to  abandon  the  practice  of 
making  a  careless  diagnosis  of  the  disease  in  every 
case  of  obscure  fever  which  proves  fatal,  and  the 
Medical  Boards  should  refuse  to  receive  a  death- 
certificate  signed  malarial  fever  without  more  spe- 
cific details  than  have  heretofore  been  demanded. 


'  ' 


<^^yin 


On  the  Visceral  Compiicalions  of  Erythema 
Exudativum  Multiforme. 


BY 


WILLIAM   OSLER,  M.D.,  F.R.C.P.  Lond., 

PROFESSOR  OF  MEDICINE,  JOHNS  HOPKINS  UNIVERSITY,  BALTIMORE,  MD. 


KROM 


THE  AMERICAN  JOURNAL  OF  THE  MEDICAI, 
December,  1895. 


i 


259  MARLBOROUGH  STREET.  B0S1 


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Jamkb  C. White.  M.D.  / 

OfriCt  MOURi    I2T03,       ^^^^^  CO^.'t^,      4><-V- 

Charles  J. White, M.D. 

OFFICE  HOURS    IIT0I2. 


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6- 


[Extracted  from  The  American  Journal  of  the  Medical  Sc! 


leiK'es,  Dcwmlicr, 


IN1I5,] 


ON  THE  VISCERAL   CO.MPLfOATlONs  OF  EIIYTIIFMA 
EXUDATIVU.M   MULTIFORME. 


By  Wilijam  Osi.kr,  M.I).,  F.R.c.P.  Loxo 

PIIOKKSSOU  OF  MKUtrlNE,  J„IINS  HOlMvIN.'-  UNlVKlf^ITY,   BAI.TI)  '' 


moi;k,  md. 


By  exudative  erythema  ,s  understood  a  disease  of  „„k„own  etiology 
with  polynorpluc  sk.u  lesio„s-l,y,,enen.ia,  u-deu.a,  and  hemorrha.e- 
arthrius  occas.onu  ly,  and  a  variable  nund.er  of  visceral  „>a„ifestatt,ns 
ol  which  the  most  important  are  gastro-intestinai  crises,  endocardi     ' 
pericarditis,  acute  nephritis,  and  hemorrhage  from  the  mucous  surfaces' 
l^ecurreiice  is  a  special  feature  of  tiie  disease,  and  attacks  may  come    n 
nmuth  after  month,  or  even  throughout  a  hmg  period  of  vear.      V. 
ability  in  the  skin  lesions  is  the  rule,  and  a  case  may  piusenl  in  o  e" 
attack  the  features  of  an  angio-neurotic  a>dema,  in  a  second  of  a  nu.l  ! 
l.)rm  or  nodose  erythema,  and  in  a  third  those  of  peliosis  rheumatic 
The  attacks  may  not  be  characterized  by  skin  manifestations;  the  vit 
ceral  symptoms  alone  may  be  present,  and  to  the  outward  view  the 
putieiit  may  have  no  indications  whatever  of  erythema  exudativum    Of 
he  eleven  cases  here  reported  the  visceral  manifestations  were  as'fol- 
nvs:  In  all  gastro-intestinal  crises-colic,  usually  with  vomiting  and 
duu-rh-ea-hve  ha.l  acute  nephritis,  whi<.h  in  two  cases  was  followed  by 
general  anasarca  an,l   death;    iKematuria  was  present  in   three  cases 
hemorrhage  occurred  from  the  bowels  in  three  cases,  from  the  stomach 
in  two  cases   from  the  lungs  in  two  cases,  fmm  the  nose  in  three  cases- 
.me  patient  ha<   spongy  and  bleeding  gums  ;  two  cases  presented  enlarge-' 
ment  of  the  spleen  ;  in  one  case  there  were  recurring  attacks  of  couth 
a-ul  bronchitis  without  fever;  in  one  case  there  was  a  heart  murnurr. 
iMve  of  the  cases  had  swelling  about  and  pain  in  the  joints 

rheskin  lesions  were  J.olymorphic,  ranging  from  simple  purpura  to 

xtensive  local  .e.iema,  and  from  urticaria  in  all  graded  an/l  forms  to 

large  luhltrating  hemorrhages  of  the  skin  and  sui,n>taueous  tissues      In 

"I'l'v.dual  cases  the  cutaneous  eruptions  were  often  of  the  uiost  varied 

ciiaracter. 

The  reu.arkable  tendency  to  recur  is  a  feature  of  all  forms  of  exuda- 
tive erythema,  [t  will  be  noted  that  of  the  cases  here  re,,orted  in  only 
one  was  the  attack  single.     In  the  others  there  were  multiple  outbreaks 

(listrihuted  over  iir>rin,lc  •...«„;..„  e.. i. ,i     .      .  . 

years. 


A  majority  of  the  cases  would  be  described  under  tli^h 


puia  or  peliosis,  since  liemorrhi 


ge  was  the  most  constant  1 


leading  of  pur 


pi; 

esioii,  but  the 


is  OSLER:    EXUDATIVE    ERYTHEMA. 

viirial)!e  character  of  the  eruption,  and  its  interchanj^eahle  nature  in 
individual  cases,  make  a  wider  delinition  of"  exudative  erytlienia  thi 
more  accei)tal3le.  A  renuirkai)le  circumstance,  whicii  I  have  not  seiii 
mentioned  in  tlie  literature  (tlioii<,fh  it  is  not  likely  to  have  been  over- 
looked), is  the  recurrence  of  severe  attacks  without  cutaneous  inanif'e,- 
tations.  In  the  first  two  cases — which  are  at  present  under  observatimi 
— one  would  not  for  a  niouient  suspect  the  true  nature  of  the  disc.isi^ 
from  the  existing'  manifestations,  which  are  entirely  visceral. 

I  will  first  give  a  detailed  report  of  the  cases  which  have  come  umkr 
my  observation. 

Cask  I.  For  six  ijairs  ncun-iiii/  f/utitrd-tiilr.-ititKif  erisrs — rn/li;,  vnnii/- 
!)![/,  (did  diarrha(L — willi  fever,  delirium  (tnil  eri/tlti'ma  inulllfoniir  ;  far  lim 
years  no  slin  lesions  irifh  the  uttne/.-s ;  enlnrt/eineiit  of  the  spleen..  —  Ben  jamin 
L.,  aged  twenty-seven  years,  Norfolk,  Va.,  consulted  me  October  ]  Ith, 
complaining  of  attacks  of  gripes  and  cold  feet,  whicdi  have  recurreil  wry 
frequently  during  the  past  eight  years.  For  a  time  the  attacks  were 
thought  to  be  severe  indigestion  with  colic.  They  recurred  at  first  everv 
two  or  three  months;  he  once  passed  six  months  without  an  attack,  Imt 
for  nearly  three  years  he  does  not  think  that  he  has  ever  been  free  for 
so  long  as  two  months.  He  gives  an  account  (corroborated  bv  that 
which  his  wife  has  written)  of  a  very  remarkable  series  of  events,  lie 
is  always,  for  a  day  or  two,  warned  of  the  attack  by  the  occurrence  oi' 

Cold  feet,  an  unerring  jjremonitory  feature.  They  are  also  cold  to 
the  touch,  sometimes  for  as  long  as  forty-eight  hours.  Frei|uetitly,  i.m, 
he  has  had  at  this  period  uneasiness  in  the  stomach.  Independent  of 
food  or  of  the  time  of  the  day,  he  then  begins  to  feel  pain  in  the  alido- 
nien,  and  has  severe 

Oripes,  as  he  calls  them;  sharp  recurring  attacks  of  colicky  pains  in 
the  central  portion  of  the  abdomen.  Formerly  the  pain  was  sivcre 
enough  U)  double  him  up,  but  of  late  years  it  has  not  been  so  inlen.-c, 
and  lie  gets  more  relief  by  straightening  himself  out  to  the  full  extent. 
He  often  vomits,  and  in  the  early  attacks  always  did  so.  Of  late  yciirs 
he  has  had  more  belching,  which  seems  to  relieve  the  pain.  In  some 
attacks  he  has  had  diarrhcea,  but  of  late  he  has  been  constipated  diiriii^r 
and  after  them.  With  the  abdominal  ."symptoms,  sometimes  preicilinir 
them,  there  is 

Fever.  He  gets  burning  hot  everywhere  but  in  his  feet.  Wiiliin  a 
few  hours  he  becomes  delirious;  as  his  wife  ex])resses  it,  he  talks  "out 
of  his  head."  He  himself  says  that  he  talks  much  nonsense,  just 
as  in  a  fever,  and  imagines  all  sorts  of  things.  One  of  his  favorite 
fancies  is  that  in  an  attack,  during  the  colic,  he  has  twentv-six  throats 
and  tw'cnty-six  stomachs,  which  are  all  in  a  row,  and  he  cannot  pick  unt 
the  one  which  belongs  to  him,  and  whicli'is  causing  the  jiain. 

I  had  obtained  this  much  of  the  history  from  him,  and  was  beginning 
to  be  very  interested,  as  it  seemed  an  vinnsual  .sort  of  affection,  when  he 
voluntarily  expres.sed  the  iufornnition  that  in  the  attacks  "  greiii  !)ig 
liver  spots  came  out  all  over  him.".  In  several  of  the  first  attiiriv-  he 
thought  he  had  been  poisoned  by  eating  something  that  had  disagreeil 
with  him.  The  spots  came  out  on  the  trunk  and  arms,  not  so  ofiiii  ou 
the  legs,  and  they  were  sometimes  so  large  that  they  took  days  to  dis- 


igeal)le  nature  in 
ve  erythema  tlie 
I  have  not  .seen 
)  luive  lieeii  ovcr- 
utaiieourt  nuinit'e," 
under  observatimi 
ire  of  tlic  (liseiisf 
sceral. 
liave  come  iimler 


ri^fx — rofic,  I'diiiit- 

ullijorinr  ;  fur  In-,) 

p/rcii. — Beiijaiiiin 

me  Oetol)er  1  Jtli, 

ave  recurred  very 

the  attacks  were 

rreil  at  first  everv 

)ut  an  attaeli,  init 

3ver  heeii  tree  for 

•ohorated   l)y  liuit 

es  of  events.    He 

he  occurrence  (if 

are  also  cuM  tn 

Fre(|uentiy,  Inn, 

Inde()en(leiit  of 

pain  in  the  alwln- 

f  colicky  jiaius  in 
pain  was  severe 
t  been  so  inleiise, 
to  the  full  extent. 
0.  Of  hite  yeurs 
e  pain.  In  some 
onstipated  diiriii"; 
letimos  precedinir 

s  feet.  Within  a 
it,  he  talks  '•  out 
ch  nonsense,  just 
e  of  his  fiivoiite 
wenty-fsix  tlii'oats 
le  (Muinot  pick  out 
e  pain. 

lid  was  heuinning 
itll'ction,  wlicn  he 
ttacks  "  jrreal  big 
le  iirst  attarii;  he 
uit  had  disaiiTeed 
IS,  not  so  ollin  oU 
took  days  lo  dis- 


oslek:    kxudative    krythkma.  3 

aj.pear.     Rome  have  l.een  as  large  as  the  palm  of  his  Jnnd      T 
a  ways  re.l,somet.n.esrai.sed,  hut  never  itch.      Durin .    u    ir,/,.       ""' 
almost  every  attack  was  characterized   hv  then,,      fer.e.  •■''"'' 

he  has  not  iiad  any  of  the  i)]ocches  on  tl,",.    1,;,       ti  •     •,   ""  >'^''*''** 

the  attack  is  froin"  six  to  ten  1    ,    s       Vtu ,      u-,.,'  ''  TT'  ''"'•""""  "^" 
the  abdomen,  particularlv  the  ri   It'si,!.       Ii  •      '    ?''  '■''''>'  '"'^  '» 

IS  sometimes  hiudi  coiore<l,but  m  t  m(n-e  hethinl-      I       •'  "'  "'■"'^' 

Thereisnosin.ilardiso   1^  M;I      ^"'^^^^^ 

healthy,  strong  man,  and  is  actively  m,';^'!  in  I  u  i  tI"''   '""'  ' 

Irmal^^^iSim^"^''^  ^'•"•""^ '"  '•""•  ^  "^^  ^^^^^'^^  ^^^'r;^:: 

the  exa.uina.ion  of  heart  ami  lungs  is  neiuive  '      "   '"''"'  '^  ''"'•'^ '' 

llie  alidomen  looks  natural;  is  not  swoll.. II      O,,  ,i        •       ■      • 
edge  of  the  spleen  is  distinctiV  pal,  d,  e     a  U -^  v      ;.!rn''''''\.''' 
fingers'  breadth.     The  stoma,.!,    s    n  ,    enlari      li         '  T'  ''•'" 

crease  in  si.e.     The  urine  is  not  albun  ii.-Tho  .'."'::'''    '  ,""  '"" 

:^±'..i'!!,:..:::ir-'""^"^'  ^'-  '^.^;  .-.'^weinng  ofX";;,!'"  ""^^ 


retiiiic  are  normal. 


The 


Cask  II.     Attach  uf  colic  for  a  year  with  Ucrlnu,  ni  ih  . 
'.d   one   outbreak    of   urticaria-  ir/jrr   ////•'^'  'f'' '''*''''''''' 

entli,  attach  «.M  ' ..Mr/ /^  ^;,/  a'"  ^    f,' f 'f '    ''    ''""i'''.      '^«*^«- 
•■f,e>nc,>t  of  ike  ../....-The  f^^H   wi!:    .  '  J^^^!!!!  ';i;"''"^'^^':'"  '  -^ 


and 

(jueMui  auach:i  wir/i   arl/intis  and,  A-.s/o/(.<  ,,/■  pnithr, 

hu;e,ncnt  of  the  .pken.-The  followiCLe  i^  fct  "ulZ^U    ''  "" 

ot  the   persistence   of   the   abdominar  svmp  oms^S  h!  ,  ^'"1 

antenna  fbr  such  a  long  perio.l   before  the  a,   ™        o     u  ^ 

erythema  exudativum.  aitniiti,-,  and 

W.E.B    aged  eleven  years,  was  seen  linst. March  10  1.S')4      r.,,.,;i    i  • 

About  a  vear  ago  he  began  t,.  have  attacks  of  severe  pain  in  t he  abd  ' 
men,  ..nnnig  on  very  abruptly,  not  associated  with  an  '  ,  s  , '  J ' 
and  often  ot  such  .scveritv  that  he  would   roll   unon  ,1,,.    I      '  '  ' 

His  appetite  kept  good  and  he  has  never  liad  any  v  mit^^"l  "n,  i  !: 
the  latter  part  of  the  summer  he  had  a  verv  '  \lr  T"  :  i  ,  F 
;v^si^,ected  to  be  pertussis.  Once  du.-il.^ IL  'nXr  h^K  i  ^^  ll  ! 
tack  of  hives  below  the  knee.     He   has  never   ha.l  anv  rlieun  •    s     ■ 

"^^irSierlh;^:;^;.,!;"  """'^  ^"^  •--•  '>"•  "^■•-^  ^^^^^ 

lheappet,tefo,- the  past  year  has  not  been  verv  good  and  he  has 
been  very  par^icidar  about  bis  food.  The  bowels' lK;ve  b.vn  re.  u  ^ 
and  the  attacks  ot  colic  have  never  been  f.llowcl  bv  ,liarrl„ea 

During  the  winter  he  remained  pale  and   had  occasional  attacks  of 
ohc,  and  the  cough  reeur.vd  at  intervals.     1  le  has  been  able       weve 
to  go  to  .school,  but  has  i„)t  been  at  all  .m.n.r  "onever, 

I'mt  condition.  A  fairly  well-nourishe.l  bov,  a  little  ,)ale  in  the 
a  e  but  the  lips  am  tongue  are  of  goo.l  color.  The  ,.u>rles  e 
feebly  developed  ;  the  skin  is  clear ;  there  is  no  purpura,  no  staii   n./ 

e.ssuit       I  he  edge  o    the    iver  can   be  rea.lily  felt  at  the  costal  mar- 
Snu     Ihe  spleen  is  enlarged  and  extends  in  the  parasternal  line  nearly 


OSLKK:     KXUDATIVK     EHYTirEMA, 


ic  iiriiic 


to  l\w  levfl  of  tlio  navel ;  tlie  edjfe  and  its  notch  are  to  be  felt  very 
plainly,  'riie  npper  limit  of  dulness  ia  at  the  lower  margin  of  tlie 
seventh  rib. 

The  lu'iiit-soiinds  are  clear,  and  there  is  no  enlargement  ot  thi^  or^an. 
The  lungs  are  everywhere  clear  on  peren-ssion,  but  at  the  right  apex 
and  right  u|)per  axillary  region  there  are  a  few  medium-sized  moist 
nXles, 

The  bloud  presented  no  special   changes  ;  the  leucocytes  were  not  in- 
creased.    There  was  a  moderate  grade  of  ansemia,  about  .SO  per  cent, 
red  bloo(l-c(ir|)uscles,   and    about    the   same  of  h;emoglobin.      The 
was  clear,  and  contained  neithi'r  all)umin  nor  tui)e  casts. 

I  confess  to  have  been  (piite  puzzled  by  the.  case.  The  hi.story  of 
protracted  colic  with  cough  and  the  moderate  auiemia  with  enlarge- 
ment of  the  spleen  formed  a  symptom-group  which  did  not  seem  "to 
come  into  the  category  of  any  recognized  affection.  There  had  been  no 
articular  troubles,  and  the  occuri'ence  of  the  urticarial  rash  last  summer 
seemed  to  be  an  accident. 

On  April  Dth  his  mother  said  that  he  had  complained  several  times 
of  pain  in  the  left  shoulder,  but  there  was  nothing  to  be  seen  inspec- 
tion. 

Under  the  free  administration  of  arsenic  and  iron  he  improved  a  >jr,vvM 
deal,  and  the  spleen  reduced  considerably  in  size.  In  the  middle  of 
Ajtril  he  had  an  attack  in  which  the  cough  was  much  aggravated,  and 
he  had  slight  fever,  the  temperature  reaching  nearly  to  102°.  There 
was  no  dulne.ss,  but  at  the  ajjcx  of  the  left  lung  there"  were  many  moist 
rales  before  and  behind.  It  was  with  great  difficulty  that  any  expecto- 
ration could  be  obtained  ;  it  was  bronchial  and  contained  large  num- 
bers of  alveolar  cells.  He  improved  very  much  toward  the  end  of  the 
iDonth. 

Fridiiij,  Mail  IS.  He  has  been  doing  very  well.  The  spleen  is 
only  just  palpable  beneath  the  edge  of  the  ribs.  He  has  complained 
since  last  Sunday  of  jjains  about  the  legs  and  knees.  I  noticed  to-d;iv 
one  or  two  bluish  stains  as  if  there  had  been  purpura. 

'12(J.  The  patient  came  again  to-day.  Last  Friday  evening  when  he 
went  home  the  ankles  were  swollen  and  red,  and  bl()tches  of  urticaria 
and  |)urpura  came  out  over  the  instep  and  first  phalanges  of  the  toes. 
They  extended  along  the  outer  surface  of  the  left  leg  and  there  W(  ri'  a 
few  on  the  right,  but  there  was  not  so  much  swelling  in  the  feet.  This 
is  the  first  occasion  on  whichhe  has  had  an  outbreak  of  pur|)ura;  with 
it  he  had  an  attack  of  .severe  colic,  the  first  I'or  several  weeks,  'fhe 
legs  and  feet  today  present  the  fading  stains  of  the  purpura.  There  is 
no  swelling  and  no  sorene.'^s,  and  he  feels  (piite  well.  The  ti'oulilc  in 
the  lung  seems  to  have  almost  disappeared,  and  he  ha.<  very  little  cnugh. 
Jtiiie  (!.  Since  the  last  note  the  boy  has  been  verv  well,  with  the 
exception  of  an  attack  of  (edematous  swelling  on  the  back  of  the  left 
hand.  Today  he  has  had  a  good  deal  of  itching  and  an  acute  attack- 
in  both  ankles.  The  condition  is  as  follows:  On  the  back  of  the  left 
hand  there  are  three  or  four  scattered  patches  of  ervtheuui  wMh  exuda- 
tion. Over  the  knuckle  of  the  little  finger  there  is  considerable  swell- 
ing, but  no  ecchyniosis.  The  right  ankle  is  swollen,  and  the  swelliuir 
extends  over  the  dorsum  of  the  footand  about  half-way  up  the  ankle. 
There  is  .=onie  heat,  and  extending  for  about  two  inches  at)ove  the  mal- 
leoli on  either  side  there  are  mottled  ecchvmoscs.     The  same  extend  half 


to  bo  fi'lt  very 
inarjfin  nf  tlic 


(1  several  times 
seen        inspcc- 


.'oninj^  wlieii  lil- 
ies of  iirticaiia 
;!;es  of  the  toes. 
1(1  tliere  were  u 

the  feet.  Thi.-i 
jiiirpura  ;  wiili 
111  weeks.  Tile 
)i)i'a.  There  i.s 
The  trouble  in 
•rv  little  eciiiirli. 

well,  with  tlif 
laek  of  tlie  Kit 
iin  aeiite  attark 
ick  of  the  left 
ma  w'tli  e.Kiida- 
siderahle  swell- 
id  the  swelliiiL' 
'  lip  the  ankle, 
above  the  nial- 
inie  extend  half 


o  s  I,  K  K 


K.Xr  DATIVE     KRVTHK.M.-V. 


way  down  the  dor.sinn  of  the  d 


le   entire    Icir   j 


loiudi  the  a 


nkh 


IIOl. 

.s   eovered   with    tin 


The  1 


eft  ankle  is  a  littl 


es  are  swollen  and  look  v 


einnant.s  of   purpuric    urii' 


piillV,  and 


walk  to  the   house,  and  eould   take   (,tr 
leniperatnre,  i)!).li°. 

'-~>h.  Patient   has   been  at  .Vtl 


•erv 


his  sh 


f^ore,  vel  he  w 


H's  and   stoel 


earia. 


iis  ahie  to 


beneliti 


lit 


iks  t 


iiitie  City  and 


ed<;e  ean  be  felt  two  t 


iin  and 


kinL,'s  alone. 


is  not  been  inaterialh 


I"";;;  t'";«l'l«^n  is  still  palpable,  an.l  th 


ha<l 


no  skin  troiibli 


Injiers'  breadth  below  tl 


Och^l), 


sinee  the  last  note. 


tie  costal   nia 


u'lnn. 


He  I 


las 


'•  3(1.  lie  iijis  been  much    bett 


an  attack  of  colie.     fie  look 


pnra  since  sprint;.     The  spleen   is  .Iccid 


I'ttty  well,  and  h 


|ml|)abl 


I 


lie  livt 


all 


vals  to  tile  l.")th  of  A 


1-  IS  not  enlari.n'd.     The  pi| 


;•'•  'I'lt.l  to-day,  when  he  had 
l.iin.l  has  no  hlotdies,  no  pur- 
:;ll.v  smaller;  the  ed;re  „ldv  jiust 


<iisappeared.      He  took   the  Fowl 


inj,'  and  moist 


ii<nist. 


er  s  solution  in  fi 


■ales  have 
'  at  inter- 


Df'i-nnber  7.  He  has"  had 


there  have  1 


lit  I  arthritis  .^ 


)een  n 


inee  Mnv. 


hve 


iiany  attacks  of  pain  in   the  abd 


and   11(1   spots,  but 


or  ten  minutes.     The  edi^e  of  the  sp] 


onien,  which  last   onlv 


is  not  enlarjred.     [lis  color  is 
syrup  of  the  iodide  of  iro 


pleen  can  still  be  telt.     The  1 


.irood  ;  his  tonjriie  is  eh 


iver 


111.     He  has  been  tak 


im.     I  ordered  the 


lit  intervals  since  last  Mav  and  cod  I 


ill''  the  Fowl 


Murrh  9,  IXi);-,.      He  l,:,s  k 


iver  oil  since  the  1 


been  at  school.     Yesterday  his  iatl 


ept  very  well   tin 


er  s 
">th  of  A 


soluiion 

ULTUst, 


■"iiirh  the  winter  and  has 


nif'ht  he  had 


tervals  tlin 


very  severe  attacks  o( 


H;r  allowed  hi,,,  lo  play  hockey.     Last 


ter. 


Tl 


lUgh  this  morn 


colic. 


I  Te  has  had  t  h 


lere  \vas  no  arthritis:  i 


111,1,^     I  saw  hi,,,  iu  ')  o'clock  •  I 


point  on  his  ri-ht  siKaildcr.     Jle  had   had  s 
numerous  piping  rales,  chiefly  at  th 


lo  skin  eruption.     He  had  had 


em  also  at  iii- 
le  seenieil   j)et- 


(ine  tender 


abdomen  was  nef,'ative;  the  s'^nl 


e  nubt  at 


'line  coujrh,  and  there  were 


!• 


previous  occasion.     The   liver 


pleen  was  smaller  than  it  had  1 


xamination  of  the 


wl 


lere  on 


pali)at 


was   not  enlarir 


ion. 


June  ').   He  has  been  niiicl,  bett( 
!  bepn  to  cough  about  three  weeks  atr,,,  and 
iit  night.      Ihe  spleen  is  a  full  hand-breadth  bel 


He  1 


:ed  ;  no   tend 
ir;    no  attacks  of  coli( 


>een 
erness 


on  any 


am 


is  a  remarkabl 


e  condition  of  right  ajie.x   a^-ain  ;  tl 


!)  spots. 

now  coughs  "  terribly" 

)elow  costal  niiirgin.    There 


liitch  than  normal  as  low  as  the"  fou'rtl 
scapula.     There  ar 


I  ri 


note  is  higher  in 


•e  many  large  moist  n 


iiiainmarv  and  upper    axillary  i 


but 


is  a  little  harsi 


'eirions. 


h  and  behind  to  the  spine  of 

les  over  whole  infraclavicular, 

breathing  is  not  tubular, 


Tin 


last 


1!>.  The  cough   has  been  b 
examina  ion,  only  just  two  (in"-ers'  I 


-etter. 


Tl 


le  spleen  is  not  so  la 


lie  resona 

L'kli 


ireadth  below  the  costal 


nee  is  still  a  little  high'  pitched  at  the  righ.  . 
eiaekling  n.les  from  the  clavicle,  extending  throu-d,  tl 


I'ge  as  at 
niaririu 


iion  into  the  axilla 

October  21.    He  has  had 
palpable;  no  colic 
tl 


It  apex  ;  numerous 
le  mammary  re- 


a  irood 


spots. 


^lere  are  now  crackling  ra, 
right  lower  axilla;  a  lew,  t 


R 


summer. 


■ecently  the 


es  at   the  loft,  lowei 


The  sjileen   is  only  just 
ootigh   has   returned',  and 


Cask  HI. 


(10,  at  the  a 


lex. 


mammary  region  and 


•iti))^. 


-Ab 


fonit  ;v((/h.s'  ;  co/lc  with  diarrh 


appearing  in  crops;  me/mna 


u'.a;  urti 


varin 


purpura  nr- 


>y,  aged  six  years,  seen  witli  Drs.  I) 


aeute nephritis;  death.    (Abstract.') 


'untonand  Agnew.     There 


was 


'  Rciwt...l  in  n,ll  in  Now  Voric  M,.,ii,,,l  Joiunnl,  ll,.,.o,nI,.r 


ISS-f. 


!  fc 


6 


osi,kk:   exudativk  erythema 


„  vluM.mutir  lii.torv  in  tl.e  iiuuily.  an.l  tlu-  .lnl,l  -.1  m.  aunt  on  tl.e  fa  he  8 
"id  '  r  of  l.ur,H."ni  bemorrluiKin..  'Hie  onnot  waB_  xvuh  ,.an,s  u  tlu 
a  kl  nlovoai.vc.olieana  an  urticaria-liko  orui.t....n.  llenw.njnvo 
?  tiu'  .wds  f,;ii..wo.l  in  ahnnt  t.n  .lays  The  recurnnj,  at  acks  ot 
^lic  were  n>o.t  .listres.in..  Ahnu,  the  (  fVh  week  atter  tl>e  o  e  t  ^ 
urine  heeanie  scanty  an.l  alhnn.inous,  an.l  sliowe.!  a  tew  hlo.Ml-empust  es 
an  n  .mM-..UH  tnbe  casts.  Alter  the  .level.,,.nu.nt  .,1  the  'I'-l-X 
attaeksof  pnrpnra  oease.l,  an.l  he  .lie.l  ..f  the  aeute  ne,.hnt,s  u.thm 
three  numths  of  the  onset  of  the  illness. 

Cask  IV.     .Wm/ «//.»•/. ;  «r//Mv7..s,-  mluneou.  /''''"'''  t'^r'-Te 
mtient    a  man  aged  tortv-six  years,  was  a.l.nitte.l  to  the  1  lula.lel|.l. 
Coital    "■"'-  "Jy  eare,  with  diarrluea  an.1  -.o.- y'  puHume  raslwu  d 
nolvuthriti<      About  eiL'htcen  months  before  he  ha.l  ha.l  a  siiniiai  verv 
V  .;  v    t  a  k   w  bieh  ha.flasted  three  weeks.     In  the  present  one  he  bad 
icn  ri  K  0    i...  swelling,  an.l   ten.lerness  of  b..tb  elbows,  of_  the  r.«b 
W,  an^  ot  the  ri.bt  ankle.     There  were  nn merons  p,u-pur  c  spo^s  m 
•u-nw  and  le.rs.     The  v.m.itinjr  whs  a  very  .listressn  j:  leatuie.      ll.ne 
vs  ;     r  adndssion  a  fre^h  ^npti..n_.,ee,n.e.l  ot-nrtu.aruunu  pu.Tur^ 
ThV  .nuns  were  not  sp..nfrv.     The  unne  eonta.ned  nu.eb   alb.u  mi  a 
minv     valine  an.l  ep  tbelial  casts.     The  patient  impn.ve.l  rapi.ll v,  an  I 
"Sn   a   nulnih  IVom  the  time  .-f  adinissi,.n  seeme.l  quite  well,  th..ugh 
nn  his  di^ehar.'e  there  was  still  albumin  in  the  urine. 

CX'^VY  (imorrha'a;  acute  arthritis  and  .„n,nt.,  nuth  purpura; 
severe  rolh  and  vomilinr,,  wdh  mccr.^ive  ontt>reak.<  oj  purpura,  ^'rtwarm 
an  laracr  extravasations;  hamaturla.  Reeovert,  ajtcr  ..<//..-<;/  t  v 
",  //  •  /.V.;/o.._.Ias.  Mel)..  a.e.l  ei.bteen  years,  was  adnntted  to  the 
John-  H..pkins  H.^spital  March  Ki,  im\  eompla.mn<r  of  P' >"  '^nd 
Bwe  in."  the  wrist-  ..ints  and  fever.  The  patient  kn.,ws  verv  httle  ot 
hi     1  dl     list...-v,  ..ther  than  that  his  lather  .be.    .,   pneumonia 

He  hai  alwavs  been  healthy,  an.l  can  only  recall  having  measles  when 
seven  v.>ars  ..1.1.  He  has  never  ha.l  rheumatism.  He  c.ntracted  g..n.u- 
rba'a  a  m.u.tli  ago  and  still  has  a  slight  .lisehargc.  . 

iiii  t  illiiessM,egan  March  9th  with  fever,  pain,  an.l  swelling  m    be 
knt;:  ami  in  the  calves  .,f  the  legs.     He  .lid  not  g..  to  1-'  >;^;    ^'J^ 
a  .li«i.ensarv  in  the  citv  and  was  ..nlere.l  an  ointment.     On  Maicli  J- 
bewnsls  became  sw.dlen  and  the  lever  increase.l,  an.     he  had  much 
pain  in  the  back.     Two  ..r  three  red  sp.)ts  came  out  on  the  skin. 
'    JWsrnI  ronddhn.     The  patient  is  a  we  1-n.uirished  y..ung  "■'"'•      \"; 
temnerature  is  !>9.5°.     The  face  is  flush...l ;  lips  re.l ;  tongue  cated  on 
the     .        n    re.l  at  thee.La>s.     There  is  now  m.  swelling  ..I  the  knees. 
Kth  wr^ls'and  the  backs  ..f  the  bands  an.l  ..f  the  l;'n.«-  -;i -'l^;; 
and  ten.ler.  an.l  are  re.l.lene<l  and  pit  on  pressure      .l^^^;^^^*'!'  f.    ■ 
the  wrists  is  chiellv  sulxaitaneous.     M..ven.ent  of  the  j.nnt  is  n..t  l)ai  ilu  . 
Ou  b.   h  l.-gs.  on  the  ankles  an.l   on  t.be  leet  there  are  ■'"•"^-!1^;^«'^  ; 
moses,  var;ing  in  si.e  f^.m,  a  half  to  live  .>r  six  -f  "-^^es^         Imy  jU. 
also  nresent  on  the  inner  surface  of  the  thighs,  and  a  lew   ai."  sc,  tt(  rt.l 
o     t       ba  k   an.l   buttocks.     About  the  ankles  th.re  are  some  large  . 
c    ilueiU  .mes.  which  are  ca,,pe.l  wHh  y^icles.     The  heart  s  ac  ion  «  . 
,,,.„„!.,-,  ,,„d  there  wre  no  murmurs.     The  urine  was  yelloVMsh  in  col..i, 
a  lini;:  ;;m4.y,  aci.i.  sp.  gr.  1025,  an.l  microscpically  it  presente.i  many 

1  Ibiil. 


OSI,  Kl{ 


KXriiATl  VK    KK  VTII  K 


M  A 


orrlnif/e-f  mid  /'*■/(- 
(Abi^fract.'t— The 
1,  the  riiiliidelpliiu 

inir|>iiric  riisli  and 
liiul  a  similar  very 
present  "lie  he  Imd 
bows,  of  the  ri^'lit 

[Uiriniric  spots  on 
iir  feature.  Three 
icaria  and  luiipnra. 
iiiich  allunnin  and 
roved  rapidly,  and 

quite  well,  though 

iV/.-i,  with  purpura; 
pnr{>urii,  urficurla. 
er  an  U/nc^x  of  two 
vas  admitted  to  the 
linin.ir  of  piiin  'i"'\ 
knows  very  little  of 
'  pi'eunionia. 
lavinji;  measles  when 
le  contracted  gonor- 


hlood  coipiiscjcs,   with    some  1 


meatus  of  tiic 
out.      .\  iiaetei 


lyaiiiie  and    a    few  cpitji,  li;,l  ca-is.     Tii 


Jienis  IS  red  and  tnoisi,  hui  no  disci 


iolo;;ieal  exainmati.in  was  made  of  tl 


liU'liC    can    lie    S(|Ucc/rd 


vesicles  on  the  le-is.     Esnuirch's  tubes  were   mad 


At  lirst  we  regarded  th 


le  material  tVoni  tli 
hut    nothing   ijreu. 


pura.  but  the  Hub.'eiiuent  history  of  tl 


e  ca.se  as  one  of  gonori'iio'al  synovitis 


grouped  as  erythema  exM.latiyum. 


le   case 


ln)w.>   thai    It    , 


with  piir- 


nii.-t    lie 


M'irr/i  17.   A    large,  swollen, 
inner  malleolus  of  tlie  rio-lil  Ic.r 


)f  m 


1  deep-seated  pain  in  the  abd 


iemorrliagic_  wheal   d.-yoloprd   on    the 
eningthe  patient  complained 


In  th 


le  ey 


18^A.  The  temperature  i 


)nien,  and  vomited 


again  this  morning  and  conmlai 


las   ranged  from   99' to  I(»I°.     Iff  v 


'2i)t/i.  The  urine  cont 


easts  are  still 


present 


aiiis  nuieh  less  blood,  I 
For  the  lirst  t 


I  good  deal  of  pain  in  the  l.acl. 


omiled 


m  tiio  i)ulmonary  area. 
2"_'»/.  The  hands  are 
its  middle  is  swollen  and  tend 


)ut  hyaline  and  e]Mthelial 
line  a  murmur  was  noticed  today 

very  much  better.     The  left  biceps  lo-dav  ah„ut 


ler,  and  it  nain 


2Sd.  The  ])atient  complains  of  a  great  deal  ot 


|)ains  him  to  nioye  it. 


below  the  navel.     He   I 


spot 


las   had   no   furti 


pain  111  the  abdomen 


s   are   present   to-day   oyer  t 


ler   yomiiinL 


le  clavicK 


nceps    has   increased  ;    extension   of  the  ar 


T 


l-'resl 


li  purpuric 


lie  swell  I lu 


)f   tl 


le  It 


'ft 


Tl 


lere  is  no  discharge  to-day  from  the  urethra 


III   is   particularly    painful. 


24lh.  A  group  of  eccl 


bice 

men,  and  for  thi 


ps  to-day  is  very  tender.     He  com] 


iynio.ses  has  extended  about    the  neck.     Th 


nior)ihiiie 
hlood-cor 
color. 


Tl 

■puscl 


n   the.  evening  he  had  to  I 


ilaius  much  ol  jiain   in  the  ab 


le  urine  s 


es, 


till 


and  numerous  hvali 


iintams  a  moderate  amount 


given  a  hypodermic  of 


ne  casts.     It  h 


alhun 


nil,  red 


iis  a  distinct  cIk 


rry 


sma 


II, 


ins 


->t/r 
tep,  capped   with  a  distinct   bleb.     ( 


rai.sed  erythematous  area  has  appeared  oyer  the   right 


vhicl 


subse(|uently  sliowe( 


2()//(.  Albumin  am 


i  t 


le  presence  o 


ulture 


le 


ftl 


'.7t/i.  Urine  is  lisrht 


casts  persist. 


s   troiu    tins   were  made, 
ordinary   pus  orgaiii-^ms. 


roved  somewhat;  the  biceps  is  be 


er  in   color,  no  blood  noted  to-day.      raiiem  1 


tter. 


las 


2m.  Within  the  ^ 
s|)ots  has  developed  i>n  the  outer  side  ot 


past  t  wen  I  ^    inir  hours  a  large  patch  of  purpuric 


right  buttocks   there   ha 
somewhat  injected  margins 


the 


left 


torearm,  ami    on  tla; 


come  out  a  crop  of  ordinary  urticaria   with 


\--<t.   No  casts  noted   in   the  urine.     I'aiient   has  had  no  abdominal 
pain  tor  .some  tune. 

AprI/ 1.  New  crop  of  purpura  on  the  dorsum  of  the  riirht  f,ot. 


fresh  articular  trouble.     Tl 


100..')' 


Tl 


le  lieart-soi 


le  temperature  has  ranu'cd  from  99    li 


ind.- 


It    th 


X.: 

luo^ 


ic  a 


Hei 


re  made  on   the  urine,  and  albumin   and  hyal 


Jiex  are  clear.      Daily  notes 


tnproved  a  good  deal,  thouirh  at 


in 


e  casts  were  present. 


lie  had  a  recurrence  of  vomiting  and  of  the  abd 


times  he  had  sweats.     On  the  15th 


crop  of  petechi:e  came  out  on  tlie  right  side  of  the  n 


omiiial  pain,  ami  a  fresh 


ill  the  abdomen  was 


iiliiod  did   IK 


^'o  severe 


that  I 


the  17th  the  vomiti 


t  appear  in  the  urine.     On  the  l(3tl 


leck  and  chest.      I'ain 
le  reipiired  niorjihine  hypoderinically 


11":  w 


1  he  was  better.     On 
us  very  .severe  and  the  abdominal  pain  most  in- 

s  clean  and  moist ; 
lere  were  a  few 


ciii^e  in  the  region  ol'tim  stomach.     The  ton-nie  was 


he  has  no  fever,  and  he  slept  well  after  the  morphine.     Th 
ecchyinoses  also  on  the  right  elbow. 


8 


OSI.KR:     KX  I'DATIVK     KKYTIIKMA 


\^f/i.  Tlio  |)iun  ii)  llie  iilxluiiu'ii  in  hcttrr.  Tln"  Um>:m^  k  to-dav 
CdiittMl ;  the  iiniic!  i.s  tiirhid,  .srnoUy,  iiml  .k'li.sci,  an  iimiHiiallv  large  iiiini"- 
luT  (if  tiil)i'  casts,  some  of  which  are  pale,  others  made  up  of  leiicocvtes 
and  a  i'ew  l)lood-('or|)Uscles. 

H)//(.  The  blood  persists  in  llic  tiriiic;  the  casts  are  not  so  niimuroiis 
From  the  20tli  to  tiie  I'lM  he  was  lietler,  no  fever.  On  the  L'lJd  a 
fresh  crop  of  pnrpiira  came  out  on  tiie  ri^^lit  instep.  He  lias  no  fever 
and  has  been  Letter;  appetite  ■rood.  He  has  gained  in  weight.  He 
iin|)roved  .|nite  rajjidiy  early  in  May  and  left  (he  ho-oital  on  The  12th. 
At  the  time  of  discharge  the  urine  had  a  sjiecific  gravity  of  101;;,  con- 
tamed  a  trace  of  aihtimin  and  a  few  hyaline  casts. 

Cvsi.;  Vr.  'f/iini  (itlad:  I'i(r/iiirii.  co/ir,  dud  me/iriKi  ;  nniilh'iir/;  vt- 
curn'ii'/  iilfiic/c-f ;  <ilbiiininurtit  \  ilmlh  (nun  ])iiriimtnii<t.~\\m.  L'., -A^nA 
uine  years,  admitted  to  the  Johns  Hopkins  Hospital  October  18, 'l,sT)2 
wmplaining  of  .^^pots  on  the  arms  and  legs.  The  familv  history  is  good': 
the  fatiier  and  mother,  two  brothers,  and  one  sister"  aie  living  and' 
liealthy.  The  mother  had  rheumatism  in  riubt  hand  fourteen  years  a.n. 
The  patient  has  always  been  a  delicate  child.  He  had  pneumonia 
when  three  years  old,  and  measles  when  si.\,  >;o  other  illne.«s.  Sixteen 
months  ago  he  had  the  first  attack  of  the  alU'ction  with  which  he  suffers 
at  i)resent,  namely,  spots  on  the  skin,  which  recurred  freipiently  with 
l)ain  in  the  bowels  and  blood  in  the  stools.  The  present  illness  "bean 
about  two  months  ago;  the  spots  first  appeared.  He  lost  his 
and  got  pale.  Five  weeks  ago  he  had  the  first  attack 
abdomen,  with  nausea  and  vomiting.  It  la>ted  all  dav  and  he  had 
several  bloody  movements,  and  there  was  a  little  blood  i"n  the  vomitus. 
In  a  week  or  ten  days  he  improved  and  remained  better  until  two  weeks 
afro,  when  an  attack  began  in  the  same  way,  with  little  pain  in  the  ab- 
domen, iKULsea  and  vomiting,  and  bloody  stools.     On  seven 


is  appetue 
pain  in  the 


nees  have  been  a  little  stiff  in   the  evening,  but   there  has  b 


his  k 

swelling  and  no  pain.     In  one  of  the  attacks  his  moti 

coughed  up  a  little  blood,  and  one  day 


een  no 


a  fresh  crop  of  spots  appeared  on  the  skin 


ler  states  that  ho 
s  nose  bled.     With  each  attack 


Present  coniliti 


0)1.. 


lie  is  a  healtbv-lookin!. 


hoy 


tl 


le  lips  and  mueons 


membrane  are  ])erhaps  a  little  pale  ;"the  pulse  isof  good  volume    104 
the  temperature  is  100=.     When  asked  what  is  the  matter  with  him  I- 
places  his   hand  on   the  abdom 
Over  the  arms  and  leirs  tl 


en   and  says   he  has  pain  and  soreness. 


the  legs  are  fading;  those  on  the  arms  are  f 


lere  is  a  copious  purjiuric  rash.     The  spot 


s  oil 


evening  of  the  lOth  he  vomited  a 


esh.     Oil  the  afternoon  and 


great  deal,  and   was  unable  t 


anything,  and  had  a  good  deal  of  pain  in  the  shoulders 
peared  in  the  vomitus  or  in  the  stools.     On  tl 


Xo  blood 


o  retain 


an- 


te morning  of  the  20th  a 


fresh  cro])  of  spots  was  noticed,  jiarticularly  over  the  shoulders  and  back. 
1  he  joints  were  neither  enlarged  nor  tender.  The  ape.v  beat  was  inside 
the  nipple  line;  the  sounds  were  loud  and  clear.  The  abdomen  looked 
natural ;  the  spleen  could  not  be  i)alpated  ;  the  area  of  dulness  was  not 
increased;  the  liver  was  not  enlarged.     The  urine  was  turbid,  vellon, 


sp.  gr 


1020 


and  presented  a  tr.'ce  of  albumin.     On   the  22d 


attacks  "f  vomiting  and  pain  and  the  fresh  crop,  the  specific  gravit 


ifter   tl 


1020,  the  amount  of  albumin  had  ii 


tube  casts  were  found  and  a  few  red  blood 


icreased,  and  a  few  finely 


V  WM-' 


irraiiulai' 


Th 


corpuscle 


e  patient  improved  very  much  on  tiic  21st  and  22d,  the  vi.mil 


ceased,  and  on  October  2od  his  mother  i 


emoved  him 


(I ;  roiiiitiin/ ;  ?>- 

—  Will.  L.',  iiL'cd 

ctolitT   18,  1,S1)2, 

V  history  is  ff^ni ; 

iuo   liviii;;  and 

iirti'cii  yt'iU'M  a^'o. 

'  had  piKMniioiiia 

iiliK'!*s.     SixtoL'u 

whicii  lie  suffffH 

t'rcMjiieiitly  with 

lit  ilhiess  hei;aii 

htst  hirf  appetilL' 

k  of  pain  in  the 

ay  iiiKJ    lie   had 

in  the  voiuitus. 

•until  two  \veelv8 

pain   in   the  aii- 

everal  occasions 

ire  lias  hceii  uu 

r  states  that  Im 

rVitheach  attaci< 


1,  tiie  voiiiiiiii<f 


<'«LKR:     KXrri.ATIVK     KKVTHK 


MA, 


Al  I 


lOIII 


"";!'■   Il'-  out   SlHUCWhal    h,.|t, 

'ic  stayed    in    i)cd,      '|'| 


"'"1  'Ik'  iiiiipiira  .lid  „.,t  dcvcl 


"toniach  or  of|| 


Itilh  oIN 


"'  \■onlltln!^ 


ir 


iiTc  was  ni 


ivonihcr,  when  he  had 


I'  I'i'iiiaini'd  jirciiv 


rt'imn  of  t. 


ii'iim,  of  which  he  died 


a  ( 


hill 


iiiifil 


wiiich   was   i;,||uw..d   I 


the  I 


cniperaliire  was  hi'di 


""  III''  '-'^th  nCX,,v,.„d,er.      I) 


op  so 

(lanis  in  the 

di.iii    |||(. 

IV  pni'ii- 


<'Asi;  VII.     //;,,  ,/ 


raiin  ;  cn/ir 


III'  pnrpnra  developed. 


iii'ii".'   tllr    ilhll 


ilini/i 


i-"iin/ni;/  ;  •irl/irili' 


(IIIIIIII.1   III 


nrotrn/.     .Alary  R.,  ajjed  lom 


'/ri'iil  dill 


"i'"rr/in,/,.;    /,iiiy,„r„    ,„■/, 


l< 


'.•""'.^■-     ■'"'"'  <'hiid  had  alw 


tills  vear,  w 


len 


years,  seen  N 
lys  heen   heait 


mil  III  fun  III, III :  ,,//, 


overiilier 
iiv  am' 


18!»n, 


iniinini'tu 


with  I) 


•■".I'v  l)r.  Iltdsied  and    Dr.    I 


'"•"'i;,'  until  .Iiine  of 


I  Wo  nijeeliiiiis  of  i,)d 


Oil   Tlnirsdav,  .\ 


lorni  ml,,  the  j,,in( 


'liivo  .synipt..ni.-.  of  hip  di.sea^e 
'iiney  toward   the  en.l  ..f  <  ),■!,, | 


the  evenniir  ll 


oveniher  Cth.  she   had   1 


were  made 


le  was 
•'■r,  and 


cred    Willi 


1)1 


K'  mother  n.iticeil  that   her  hand 


H'eli    restless  all  da 


ni.-li 


had  sliirlii    f^.^.,,,.  , 


<pot.> 


Dr.    I 


I'lney  saw  her  thai    ev 


were  swollen  and 


swollen  appearance  d 


eniperature  al.out 'lOP,  an.i   the  hand 


en  I  Hi:,  wl 


y.  and   in 


cov- 


en she 


iietosuhcntane.Mis  h.cali/ed  inlil 


JliviUi;  a  curious  patchv  hlneness.      Tl 
well  as  the  ilor.sal  surfaces.     The  f 


liesc  were  seen    .m   tl 


sive  pur|>une  urlicari; 


liirly  scattered   over  the   lindi^.     '| 


lie 


's  ol  any 


d'llu 


II  aiioiit  the  ell 
'1 


lollowinir  die, 


presinted    a 

"■"lions  with  hlocd, 

le  palmar  as 


On  the'sth  slu'  i 


joints 


fiow.- 


lere  was  IK 


'(■re  was  a  verv  e.xten- 


ankles  and  kiiee.s,  and 


irrcgu- 


pecnil  swellin.r  or  sore- 


eliaracter,  coiniiiir  ,,i,  .,(,  j„f(, 


•egaii  to  have  uaiiis  i 


and  i 


ree  f'l 


rvals  with  voniiti 


II  the  ahiloineii  ..f 


I -.11.  u-l  '"""""I""":  tlH'>)owcls  were  not 
'•'llj.  "hen  I  saw  her,  she  had  in  hricfthef, 
eessive  crops  of  „,„.st    e.\teiisiv(!  ciita 


loose, 


fi  I'rampdike 


lie  urine  was  clear 
'fiiii  the  8lh  to  the 


owiiii,'  .symptoms: 


;"■"'  "'    "I'ticaria,  hut  „,,^  , 

""•"I'.illi  tlic  skin  only  a  hhiish  .liJI 


iieoiLs   liem.irrha;,'es,  chiell 


'i'>»'i.v_  were  deep,  suhculaneous.'and 


small 
Icet  wer( 


•'i-  purpuric  spots  not  rai.sed  al 


use  color. 


Tl 


swoll 


en  and  the  anki 


love  the  surface  of  |lu;  sk 


tiere  were  alsi 


in. 


y  in  the 
pic-cnted 


'  niaiiv 


lints  (lid  not  seem  to  he  allected'. 


t'-joints  eiilaived  aii.l  tender.     1 


Tl 


^'rentlya'denial..u 


completely, 
were  seveial 


Tl 


and  the  swell 


*)ii  the  iL'th  the  lorehead  1 


'he  otl 


lis  swelliiH'  was  not 


iijrextended  to  the  eyelid 


associated  with  I 


:s.  closin:,'  th 


IK 


pots  on  the  face  and  ears.     4.  1 


leiiLirrhat'c, 


■■■^-^--olhat  the  slightest    tone! 


rXireme 


ic 
'ler 


iiccanie 
leni 
There 


:eiieral  .sensitive 


luin.s,  ciinsistinj'  of 


i.-eemed  painful.     .').  .Ah.lominal 


ihslinati 


paroxysmal  attacks  of  colic  of  ;,q'Jat 


she  had  heen  t 
lo.iked  hriirjit. 
mucous  suiface 
with  fadiiii:  eccl 


voniitin.!:.     At  the  tin 


"r   tour   d, 
Tl 


IV." 


le  ot  my  Visit  the  child  was  hetter  il 
-  le  was  sitting  up  in  hed.  and   the  I 


le  left  cheek  was  .swollen,  tender,  and 
liatchy,  whiti.sh  appearaiiee.     Tl 


lyniose; 


sy  111  p- 
cverity  and  of 
lan 
ice 
presented  on  the 


Th 


le  arms  were 


'"'i'lmtion  oftheskin.andon  the 
suhcutaneoiis  iiililtrati..ns      Tl 
hut 


o.-^e  ahoiii  the  elhow  were  stil 


coverei 


hand 


on  hoth  si.lcs  tl 


raise( 


fi 


lere  were  hluisi 


were  tolerably  ahiindant 


pots  were  not  nunierous  on  the  tl 


•lUll 


I  he  hill  locks,  where  tl 


upon  the  ahdomen  and  verv 


llieiialches  almost  covered  the  sk 


iiey  presented  the  appearance  of 


lorax, 
numerous  over 


surf 
sni 


iices  of  the  ki 


licutaneoiis  infillrat 


knees.     Thv  ankles  looke.l 


selves.     1 


iiui  than    from   invol 


in  of  the  face,  and  ah.iiit  the 

arge,  rather  it  seemed  f'n 


ordinary  urticaria. 
exteiis(U' 


vement   of   the    joints  tl 


icii,  the  skill'  t 
with  hlood 


icy  were,  however,  painful  on  pressure.      The  i 


use  due  largely  to  a  dillu.se  sul 


rhe  ahd 


lomen  wa.s  not  tender,  ther 


lem- 

eet  were  swol- 

liciitaiieoiis  infiltration 

•e  was  n.i  enlargement  of 


10 


OST,  KR:     KXl'DATIVK    KRVTHKMA. 


the  liver  or  wpli'cn,  the  licarl-.soiiiKU  wfrc  iidiimiiI.     Tlic  l>lii(i(l  uus  cxani 
iiii'd  hy   Dr.   TImyi'r,  and  sliowcd   iiotliiiijr  s|>ccial  cxccpl    u  ftli;,'lil    in 
(■reuse  in  tlie  miiiiiier  of  leucocytes.     T!ie  l)ou(>l<  were  c..i).sli|.ate(r.     'i'lie 
urine  .xeeiiieii  mnMnal  in  i|iiantily  ami  c(pntain(ii  a  trace  (if  allinniiii,  Itiii 
no  i)l(i(iii. 

^  Dr.  Finnc.  had  ^'iven  various  rnncdics  witiioiil  s|)ecial  iiitluenee. 
Er;;ot  was  employed  witiiout  .snece.s.s.  Tiie  solution  of  morphine  seemed 
to  be  nioHl  eflectual,  allaying  the  pain  and  jrivini,'  the  child  sleep.  The 
child  recovered  completely. 

(.'Asr:    \'III.     SHijIit   IniiDiiii  :  cm/ts  <>/  /turjuini  :  mt   iirlhri!l.-<:  .vrer-' 

cnlir  irit/i  iliiirrlidd  ;  aniti  nrp/irili-- ;  i/nin-'d  iiiKtsiircn  :  unniiia  ;  iIkuIi 

Olive   L,  ai,'ed  live  years,  rctcrrcil  to  tne  l>y  Dr.  (ioldsltorough,  ri  (Jam- 
l)ri(lj,'e,  iMd.,.luly  II,  I8'.ll,  with  general  anasarca. 

Tile  (iitlier  has  sn  tiered  much  at  times  with  rheumatism;  the  inothir 
and  three  other  children  are  well. 

This  was  the  first  child  :  she  had  always  heen  strong  and  roliu.'<t. 

On  dune  llth,  Just   a  itli  ago,  while  playing  under  a  ciierry-lrcc, 

fhe  struck  her  toot  against  a  chair,  and  complained  very  much  to  her 
rnother  that  it  hurt  her.  Very  soon  she  could  not  move  the  leg,  and  liv 
nigiitfall,  it  h  stated,  that  she  could  not  move  either  leg.  A  .small  con 
gested  spot  was  seen  on  one  ankle,  and  it  was  thought  po.s.sihie  thai 
soinethii.g  had  liitten  her.  The  next  day  a  rash  ..iune  out  on  the  skin 
of  the  legs,  irregular  patches  of  a  hrighi'red  color,  which  witliii:  twelvr 
hours  turned  to  a  dark  purple.  For  two  weeks  they  eanie  out  in 
crops,  and  as  they  disappeared  (edema  of  the  feet  wa.s  noticed,  and  the 
urine  hecame  scanty.  There  was  no  luenuituria.  The  howels  were 
regular;  her  apjietite  was  po(w,  hut  she  had  at  times  .severe  pains  in  the 
ahdomen. 

J'risi  III  roiidilioii.  The  child  presents  general  anasarca  and  is  verv 
ana;mie.  The  tongue  is  moist;  pulse  100;  no  increase  in  tension:  iIh 
temi)eratnre  is  normal.  I'pon  the  skin  of  the  legs  to  the  middle  of  ihf 
thighs,  and  upon  (he  arms  to  the  elhows,  then;  are  irregular  brownish 
stains  from  5  to  .'10  millimetres  in  diameter.  The  examination  of  tin- 
heart  and  lungs  is  negative  ;  apex  beat  is  in  nornuil  position.  The 
abdomen  is  large,  and  there  is  dulness  at  the  .lanks,  but  the  chief  dis- 
tention .seems  to  be  due  to  tym|)any.  The  .spleen  is  not  palpable,  and 
the  liver  is  not  enlarged.  The  anasarca  extends  to  the  back,  and  is,  ..l 
course,  most  marked  on  the  legs  and  thighs.  The  urine  was  not  exam 
ined  at  the  hospital,  but  Dr.  ( J(ddsi)orougl),  who  had  made  fre(pient  tests, 
stated  that  it  presented  both  albumin  and  tube  casts,  but  no  i)lood. 

Dr.  (Joldsborough  wrote  sul)se(piently  that  the  condition  of  the  patient 
did  not  im))rove  in  any  way.      No  further  attacks  of  purpura  occurred, 
but  she  ha(I  fre(|uently  colicky  pains  and  diarrhiea.     The  anasarca  con 
tinned  in  spite  of  all  measures,  and  she  died  with  unende  coma  and  con- 
vulsions. 

Casic  I\.  Arthritis;  imrpiini  iirticmis;  co/ic  imd  rainitiiK/  :  ri'dirrrn. 
—-Lewis,].,  aged  twelve  years,  admitted  January  2,  iMIo,  with  inleniM 
of  the  legs,  pain,  and  pnrj)ura. 

The  family   is    healthy;    there  is   no   history  of   Inemophilia.     One 
brother  has  been  treated  in  the  hospital  for  rheumatism. 
The  patient  has  had  measles,  varicella,  and  mumps, 
i'resent   illness  began   lJecend)er  Iti,  1.^04,  with    pains  in   the   leg-. 
The  left  ankle  was  swollen  on  the  "ilst  and  remained  swollen  up  to  i!iv 


loixl  wiiH  cxaiii 
■|i(-   II  .sli;;lit    ill 
nsliimtcd.     'I'lic 
il'ailiuiiiiii,  liiit 

icciul  iiilliu'iicc. 
or|ihiii('  siH'iiicil 
lilil  sii'i'p.     'I'lif 

ini/irilii :  .vver-- 

•vmlii  ;  ih'cili 

irinij,'h,rt'  (1iiMi- 

III  ;  the   iiKitlii'i' 

likI  roliiisl. 
r  ti  clKTry-trcc, 
•y  inucli  to  liiT 
the  lej^,  and  liv 
A  small  roll 
t  |M)ssil)lt'  ihiii 
lilt  on  the  .skill 
1  within  twelve 
y  came  out  in 
itieed,  and  llif 
le  howels  were 
■re  paiiiH  in  {lu' 

I'ca  and  is  very 
in  ten.sion  ;  the 
!  middle  of  thi' 
;iiliir  hi'DWiii.-li 
lination  of  tiir 
lio.sition.  The 
t  the  chief  dis- 
t  palpable,  and 
)aek,  and  is,  i<\' 

was  not  exam 
1  freipient  tests, 

no  htood. 
1  of  tile  patient 
pnra  occurred, 

anasarca  coii- 

eoma  and  emi- 

///(//  ;  rrcarri'ii. 
"),  witil    (i'delii:l 

lophilia.     Oiii' 


s  in   the   le; 
illeii  III)  to  M 


"■^'-KK:     KXI|,.\r,VK     KKVTMKM.v. 


11 


"I  "I'ly  ,,i,   motion.     R,,,| 

"'■  '""I  "'"  ot||,.r-w,.|li,|._r  :,,|,| 


;';";■  "Hii.  visit  „„  lU,^.  Mih.     n   was  pninf, 
'>'"lelies  came  out  on  the -.'Oil,  and  •'Ist 
Jio  ahdomiiial  pain  at  this  attack 

;::i:'::;'  Xz  ;;i:;;;:;;;""'i.;riV;  -^i.,  -i^  ;.;;;;;,.„l'::i''„ ;;,,;;:: 

™  .1.     TI..-  |»,n,„ri..  n„l,  ™,..„;'i;     ,  ,1  :";,„k'".,;',""'  ^•'•<'-<-«M 
Ihe  heart-.soiim  sare  clear      Tin.  ,!.,,   ...  ," 

fi.'lin.      ()„  thesanu.  di'  'an     "  „       ,"ri'  :"  7'^''i';'  "-■  n.sl.  .a 
'"i"<'l<,  which  lH.^a.i  with-v      ;;.,""  ".'"""^''.""  'V"'  "  very  s.ven 


,,,,     I  ,,       I  "'   it"    the  clicsi. 

"      '">  .^^''^'l'  ^^■"  '-"^v  him  the  rash  was 

Piii-Mura  came  out  «•!.!,  il,;.  „...,.         ■        "  '".  '"■''■     -^   ''■<'>l<  eroi,  of 


He   has  heeii   'a'tlin-r   |„ 


f 
Her,  liut 


small, 
il<les  arc 


le  a  httle 
idiiiir  pur- 
no    loljcrcr 


piii-pura  came  out  with  this  attack 
hi.s  IcL's  have  remained  swollen. 

<)n  admission   lie   Un,]   .,    (•.,i,.i,-  ,,    ,  i        i 
swollen   hut  no.  spongy.'     rr 

lu'liilriHiamfiS.''^^^^'''''"^-'^-'^^  "'-I.'.,  am, 

Ontliel,.th  he  had  a  fresh  eruption  „n  the  I.m.s   u,,]   ,1,1   i 
•I"''"  nitaiieoii.s  and   purpuric  in  eharieter       il.         i  -  "'  "'""    "^ 

"-.-  tissues,  lookini  lib./!^.  :    i'     -."^iv'i;,''';'''''   ""■-'>-;ta- 
Hwollen.     ile  hud  no  colic.     There  was  m,  all         '  '     "'""'    """^"'"'^ 


te,„l,,„.v  i„  |,|„„|'       •-  '"'"I'l-"'""!-'  "1  •«-.'llii.K  ..I'll,,.  ;,„„,,  ,„„|  „ 

»n,^";::''"'i.'S,I;'',,';;'i';;r,,:;r  "r'  ■''  '"r"""^-  '■■ -  -- 

"«...a-...  uk.„  .,?^L:i',,»    .. ;;  I  r'r;  i,"""i,  '■" » ,"'• 

al  liiis  lime  i;,r  !«■..  weeka  -r'"  "n    ml.-.     II,.  »,u  in  1„..| 

£r''^.;ri-?f;'i'""'.'«""'^i»Si,i;:';s,,l:^ 


le 

lie 


'iMt 


12 


OSLKH:     KXlliATIVK     K  It  V  I' II  K  M  A  , 


li'jfM  iitnl  iiriiiM  (mill  cpmcc  nt'llif  liicc)  lic.'ciiiic  cnvcivil  Willi  rai.-'i'il  hlui-h 
j>p(tt!<.  Tlif  cliill  (■iiiiiis  tiixi,  its  M  rule,  mill  is  imi  alwiivs  Vfiv  fU'vcic 
Liitt'ly  lie  has  liiul  no  cjiisiaxis,  (inly  llic  hici'iliiij;  riniii  ilic  i,'iiiiis,  'I'lu; 
jiaiiLs  ill  ihc  aliilonu'ii  arc  (if  ;,'rcat  iiilcii.xity  ami  arc  liko  onliiiarv  colic, 
riicy  lairiy  last   iimrf  lliaii  ImlC  an   lunir  to  mi  lidiir.     The  V(iiiiitiii;j 

I1118  ^-oiiu'tiincH    Ih'cii   Hcvciv;  he   never   In ujlit   ii|)  m.v   lilnod  ;  neve" 

pasHcil  Iddiiil  in  the  stools  or  with  the  urine.  He  has' never  hail  aiiv 
piiins  in  the  joints. 

The  |iatieni  lonks  |iale,  hill  he  is  iint  |iroroiiii(lly  aiia'iiiie  ;  the  inilse 
i«  ,L,'"o"l,  a  little  jerky  ;  the  i;iiniH  are  swnljen,  s|ion;.'v,  hut  are  not 
hieeiliiii;.  'l"he  skin  of  the  iirnis  mill  le;.'s  is  covered  with  reiiiniint.>4  ot' 
the  attack  of  fmr  weeks  airo  ;  some  of  the  stains  are  liiri'e,  as  if  the 
rash  had  hcen  |)nr|iiira  nrtieans. 

'i'lie  heart-soiiiiils  were  clear.     The  sjileen  was  not  enlarj,'ed. 
I'alitnl  soiij^iii   direction  with  reference  to  the  possihle  prevention   of 
the  attacks.      He  was  onlered  P'owler's  sohilion  and  the  juice  of  half  a 
ienioii  twiee  daily. 

I  heard  ol'  tlii.s  patient  on  the  l.lth  ,,f  iM'hrnary,  18i)ri.  Dr.  O'Hrien 
tellrt  nie  that,  with  the  exception  nf  mie  sliyhl  attack  slmrtlv  aller  he 
saw  me,  he  has  had  110  oiitiireak.  Me  took  the  Fowler's  .solution  at 
intervals  for  a  Ion;;  time,  and  atlrilnites  his  recoverv  to  it. 

(".\si.;XI.  Fur  j'liiir  ijidr^  ricnrrlii;/  <ifl'ic/:.-<  (,f  cn/ic  irltli  hiiinalfiiiisi.-<, 
miliViKi,  piir/iiini.  niid  itrll,,-lll.i.~\mw  U.,  a';;ed  eiirlitcen  years,  seeii 
at  the  Derniatolojrical  Dispensary  with  Dr.  ( iilchri.sr,  June"  L'!»,  l,S!).'», 
complaining  of  mi  extensive  heinorrha^ic  eruption  on  the  arms  and' 
legs. 

In  duly,  |S!I|,  when  she  was  fuiirteeii  years  old,  she  had  the  lirst 
attack,  which  lR<;an  with  vomiting  and  cramps  in  the  ahdomen.  l-'rom 
her  mother's  description  it  must  have  heen  of  great  severity,  as  the 
stomach  synijitonKs  persisted  for  live  or  si.x  weck.s.  The  cnitnps  were 
of  such  severity  that  she  went  off  into  spasms.     At  lirst  the    vomiiiis 

wuw  not  colored;  siih.sei|iiently  .she  vomited  lilood,  and  she  passed  hi I 

from  the  howels  and  in  the  urine,  and  once  coughed  up  hlood,  .\houi 
eight  weeks  after  lu'r  illness  liegaii,  liefore  she  had  recovered  her 
strength,  hlotches  a|i()careil  on  the  arms  and  legs,  and  she  had  pain 
and  swelling  in  the  knees,  elliows,  and  lingers.  In  this  attack  she  was 
in  1  led  very  ill,  and  crops  of  purpura  recurred  mi  and  oil  until  Jan- 
nary.  Then  she  got  hetter  and  remained  well  until  the  following 
August,  when  ,s|ic  had  a  second  attack,  which  was  not  so  severe,  as  she 
had  not  to  go  to  hcd,  hut  it  had  the  same  characters  of  cramp  in  (lie 
ahdomen,  nuich  vomiting,  and  the  skin  eruption.  8he  has  had  no 
arthritis  since,  and  no  hieeding  from  the  mucous  niemhraiies.  Diirinu 
the  past  two  years  the  attacks  have  recurred  with  great  fivipicncy,  and 
she  no  sooner  recovers  from  one  attack  than  another  hegins  to  develop. 
She  has  not,  however,  had  cramps  for  two  vears. 

Prr.yiit  ri.iKlilloH.  .She  is  a  healthydooking,  well-nourished  girl  ; 
color  is  good  ;  tongue  is  clean.  The  guni.s  are  not  spongy  (her  nuitliei 
says  they  never  have  heen  swollen);  the  tonsils  are  not  enlarged. 
None  of  the  joints  are  swollen.  There  is  an  extensive  hemorrliai.'if 
eruption  011  the  arms  and  legs,  chiclly  on'  the  extensor  surfaces  of  the 
arms  and  ahmit  the  elhows.  The  rash  does  not  extend  to  the  chc.-t 
and    hack  and   there  are  no  spots  on  the  hands  or  on  the  face,     'fhe 


skin  of  the  lower  e.xtremities  is  extensivelv  involved  ;  tl 


ikl 


le  an  tiles  are  :i 


til  niisi'il  hliii^^li 
iivrt  Very  .><i'vcif. 
the  ;riiiii-».  Tlu! 
'  onliiiiiry  viA'w. 
Tlic  vniiiitirij,' 

V     liliiiill  ;    IK'VlT 

iii'vcr  liMil  iinv 
■mic  ;  till'  |piilsc 

',     1)111     lUV     Illil 

til  rt-niiiiiiitH  (if 
liir^'o,  ;is  if  I  he 

:  |)n'Vi!iiti()ii  »{' 
Jiii(M'  of  half  ii 

,     Dr.  O'Hriin 

liiH'tiy  iiHcr   he 
t's  .suliniiiii   ill 

'/i  /in)n((^'«)('.-i(.s\ 

et'H  yi'iifs,  si'cii 

riiiur  '_'!»,  !«!»:», 

tilt,'  ariii.s  1111(1 

'  had  the  lirf<t 

lollUII.  i"'llllll 

(■verity,  as  tlu^ 
e  (M'iuniw  wvw 

t  the    voniiiiis 

(■  passed  hjdiiil 

Itldixl,     Ahdiii 

let'overi'd  Iht 

hIic  liad  jiaiii 

attack  will'  was 

iitl   until  .laii- 

tlie  fdlliiwini^r 

I  severe,  as  siie 

craiiip  in  tiic 

e    has  had  im 

lines.     Diiriiii: 

'iv(iuency,  and 

lis  In  develii|i. 

(Uirislied  jrirl ; 
y  (her  nnitlier 
not  enlaijrcd. 
i  heiiiiirrliaL'ic 
iirfaees  (if  tin 
to  the  cih.-; 
le  face.  Tiie 
!  ankles  arc  :' 


<).H|,K  K 


KXCMATIVK    KIIV 


Tit  KM  A 


I'""-    ,""•  '.'iipiiun    IS   very  al.midant   al 


13 


ill    over  tliciii    ,| 


tii'«^  niaiiy  tad  in:.' 


licinorrhaLii's  in 

raised, 

knees. 


ri 

Ft 


I'liices  are  eonlliient. 


alioiit    ihe    knees,  ^^|H.|,     || 


I'at 


le  ern|)ii.in    is  soniewiiat  sviuniet 
IS  also  very  alnindaiit  on  th'- thi.d 


nine  of  (lie  paleli 


'  s  ai'i-  a 


rieally  distri!)iile(| 


>ii   till 


"III  seen  iij;aiii  Oeioher  7,  I.si»,-,.     si 


solution,  and  has  liei  n  in   i 


iiier  s 


ihe   I 


las 


had   f 


•uv   attack 


iiaiiy  wavs  riinch  heti 


IMS   lieen    takiic  Fouler's 


voinitiii;;  lieiran  in  liie  even 


"lie  with    vondliiii;'    and 


lllnlluji  .||,,  ^1,,,,. 


Tl 


tl 


ic  siiots  canic 


111,1,'  ahoiit  >i,\  (I'eloek 


"I"  \Mlh  j.'reiit    raiiidiiv  and 


unii 


lie  ariiH  and    je^rs.      hi    one  of  || 


Were 


swollen   and    lender.     In 


le  attacks   the  ki 


lasted 
very  e,\le||.ivc   over 


A.,M. 


snial 


I '■  the  attacks   Dr.  (iild 


lecs  and  ank 


les  were 


|i<'t.  of  the  iMirpiira  and   loini,!   „,,  | 


that  the  heniorrl 


At  t 
'I'll 


ia<.'e  Wi 


lie  time  of  the 


liellv 


aiiiiui  till 


ll'ist     rellloVld    II 

i"w  lieantifnljv, 


present  visit  ijie  ski 


lis    sectiiiiis  -1 
hair  follieles, 
I  i>  almost  eniirelv  cle;ir. 


visceral  lesionH  of  the  various  t 


fully  studied  l)v  nianv  ol 


y pes  of  erythema  have  I 


)servcrs. 


anil 


II  erythema  ikmIosii 


in 


pericarditis  have  hceii   freipieiiilv  disscrihed.     ] 


teen  care- 
Ill,  endocardiii- 


et  with  heart  complicalion 


.ewiir   III   o.s  e 


:iscs 


leu  iiistaiiees  of  heart  alll'cti, 


the  t 


ype 


ervthciua   eh 


.-i.v  time,.,  and  Stephen   .Mackenzie'  lound 
'11   III  llW  ca.seM  of  erythema  no 


|iains  in   ij,,,  j,,i„t,_  the  all 


iiraeteri/.ed  by  lieniorrh 


sum 


niatica     the  visceral  coiiiplicati 
f'rei|Ueiit  than  in  erythema  nod 
nephrit 


ection  ktiown  as  purj 


In 

ii;rcs  and  ledema  with 


"lira,  or   peliosi,^,  rlieu- 
"iis  are,  as  Kaposi  remark.,  much  more 


OSUIII. 


Tl 


IS  ail. 


acute  eiidocar 


diti 


icy  arechietly  albuminiii 


ia  with 


Ever  since  Willaii  i  ISO.S)  de.scrilied 


violent  vomitiiiir, excrii 


ill},'  of  the  letrs,  tl 
rkal 


a  case  (if 
••iatiiiLT  pains  in  the  |)„u-,. 


purpura  asMiciaied 


uiih 


li'dis,  and 


iiniiil 


h 


rcmarkahle  symptom  complex-.     () 


!s.  and  aiia.sa icons  swell- 
iive  licen   reported  with   this 


of  C; 


pecial  interest    inasmuch 


lie  of  Ihe  earliest  ca.ses  hv  (, 


as  with  the  e 


iivier   IS 


.simple  (edema  of  the  eyelids  and  of  the  hand 


eeliviiio.ses   there    was 


also 


If 


enoch'  in  l,s74  a,„i  j,| 


il>rr  h'iiKlrrl-nnikht'lIni,  called 
CoutyMcseril.ed  the  ( liij,,,,    .,.v  .^ 


»i>  in  the  various  editions  ,if  jiis  I',,,/, 


atleiitiiiu  lothi,- 


voiis  oriirin. 


comlimationofsympt 
special   form  of  purpura  of 


''<i(tit/fii, 


onis 

Her- 


Of  hit 


e  years  an   allempt  has  heeii 


examples  of  an    independeiil   d 


made  to  ,se|iara,e  lhe.se  case; 


as 


'  iirpiinf.      V.  Dii.seh  and  II, 


l.scasc,  which    has    lieen  called    II, 
II 


iielie.  111  Henoch's /'(W.vr//r//?  for  IMMI,  i 


lave 


:ie  ca.ses,  and  a   tal 


iiilatcd   list  of 


^nven  an  exluur-tive  description  of    tl 

.eventeeu  cases  in  children,  and  twentv-two  iu  adults.  '"  Thi'vcondud; 
lat  the  cluneal  picture  i 


heretofoi 


ire.sents  didiuviices  from   the  I 


■e  recof^iiizcd,  which  are  sullicicnt  to  estahlish  a 


'onus  of  purpura 


and  well-dctiiicd  t 


ype  of  disease. 


n  iiideiicndciit 


'  I'liarili!  .ViimuIl'Ii,  lid. 


IllTl 


ilHM-klill,  WncI 


iottf  Ilc'lidoiniulairi.'.  is 


KMisi'lirift,  1S7I. 


'-'  Cliiiiciii 


■uL'ift.vV  Truiisaeti 


Aivliivi'Sile  .Mid,,  |.-J7 


(m.i,  vol.  xi.v. 


14 


osT-KH:   KxruATivK   khythp:ma. 


Though  Wilhui  gave  a  graphic  descriptioii  „f  a  case,!  his  Hvmptoin- 
grouphasnot  attracted  special  attention  fn.in  En-lish  and  American 
writers.     Among  the  51  references  in  the  article  by  v.  Duscii  and  Ilociie 
there  were  only  three   Knglish  and  no  American  cases.     Of  the  recent 
text-books,  that  ol'  Md'all    Anderson'  nnikes,  as  far  as  1   can  see,  no 
menlion  of  it.     Crocker'  refers  to  two  cases  with  gastro-intestinal  symp- 
toms.    Malcolm  .Morris^'  is  silent  on  the  subject,  with  the  exception  of  a 
brief  reference  to  cardiac  complicati.)ns  in  peliosis  rheumatica.     Kaposi' 
lays  nuich   stress  on   the  internal  conii)lications,  among  whijh,  under 
erythema  nuiltiforme,  he  mentions  hemorrhage  into  and  gangrene  of 
the  pharyngeal  nmcosa,  hemorrhage  frum  the  kidneys,  .sevc"re  arthritis, 
eudo-and  pericarditis,  and  pneumonia;  in  erythema  nodosum,  besides' 
the  colic,  acute  nephritis  ;  and  in  purpura  or  peliosis  rheumatica,  hiema- 
turia,  and  endocarditis.     Ii>  the  works  on    skin  diseases  by  American 
authors  the  special  symptom-group  to  which  I  refer  is  scarcely  menti.me.l. 
In  addition  to  those  collecte(l  by  v.  Dusch  and  Iloche  there  are  cases  re- 
ported by  Ku.ssell,-'  McKay,"  Dutt,' Collie,"  .Monillot,''  I'renti.ss,'"  and  two 
cases  by  Musser."     Other  cases  are  reported  by  Silbermann." 

When  one  considers  iiow  benign,  as  a  rule,  in  all  its  types,  is  the 
course  of  exudative  erythema,  the  mortality  of  the  cases  with  severe  vis- 
ceral complications  is  remarkable.  Of  sixty-one  cases  (including  th(^se  in 
V.  Dusch  and  Hoche's  table,  the  additional  ones  which  I  have  collected, 
the  11  cases  here  reporte.l),  there  were  thirteen  deaths,  a  percentage  of 

Of  the  visceral  manifestations  by  far  the  most  common  are  the 
Ga.-'tro-inteMimUc.rUcx,  which  are  claimed  as  the  distinguishing  charac- 
teristic of  Henoch's  purpura.     The  features  are  very  varied.     There  may 
be  simi)le  colic  of  all  grades  of  intensity,  from  a  transient,  readily  borne 
belly-ache  to  an  attack  of  such  agony  and  duration  that  repeated  hypo- 
dermics of  .nor])hine  have  to  be  given.     Vomiting  and  diarrhoea  are  fre- 
quent, hut  not  necessary,  accompaniments  of  the  attack.     In  some  cases 
the  vomiting  occurs  without  the  colic,  or  a  »r,,.,-o  attack  of  vomitin- 
and  diarrlnca  may  accompany  the  outbreak  o    th-  ,.urpura.     The  attack 
bears  no  relation  whatever  to  food,  and  may  .    w.e'on  abruptly  in  a  i)er- 
son  iu  excellent  health,  an.l  in  Cn.e  II.   (in  which  the  colic  occurred 
alone  so  frequently)  the   boy's   mother  could   never  notice  any  circum- 
stances which  increased  the  liability  to  the  trouble.     An  identical  form 
of  cohc  IS  de.scril)ed  iu  the  so-called  angioneurotic  .edema,  many  cases 


-  liisi'nscsol  tlio  Skill,  Jd  (.'diihiii.  |i,  ii . 


'  IiiswisosiiC  Uio  Skill. 
^  Diswiscs  (if  llio  Skin,  IS'.il. 
<  I'athnhmie  iiiKl  Tliumpio  ,Wr  IfiiulknuiklKMlcii,  VieiU'  .\.illaKO,  ISM 
"  liritish  Mudiciil  .loiiniul,  i,s,sa,  ii,  .,  i|,j,i     ,,,^|.,  jj' 

'  "'i'"-.  l-^ss.ii.  .  ,.a,„;',i,  ls:H,i 

'  IninsiU'tKiii.-iuf  the  .Vrink-iiiy  (if  Mi-diriin.',  Iiciiui.l,  vol.  v. 
I"  Trioisiii'tioii,sof  tliu  A,ssooiiiti(iii  ol  .ViiiiTiciiii  l'livsiiMiiii«  vol   v 
"  "'*'•••  ^■"'-  ^''  '''^  lIoiioJii's  VoslM.lirin. 


MA. 

use,  this  syinptoin- 
lisli  and  American 

Duscli  and  lloclie 
?s.  Of  tile  recent 
I"  as  I  can  see,  no 
ro-intestinai  symp- 
the  exception  of  a 
iiniatica.  Kapo.>i' 
ong  wlii.'li,  under 

and  gangrene  of 
's,  severe  arthritis, 

nodosum,  besides 
heumatica,  hiema- 
ises  hy  American 
;arcely  mentioned. 
I  there  are  civses  re- 
I'rentiss,'"  and  two 
mann.'^ 

1  its  types,  is  tiie 
eswith  severe  vis- 
including  those  in 

I  have  collected, 
S  a  percentage  of 

ion  are  tlie 
iiguishing  charac- 
•ied.     There  may 
Jnt,  readily  home 
It  repeated  hypo- 
diarrhoja  are  fre- 
:.     In  some  cases 
tack  of  vomiting; 
ira.     The  attack 
hrujitly  in  a  jier- 
le  colic  occurrc'i 
itice  any  circiim- 
n  identical  form 
ema,  many  cases 

1.  Jil  filitiull,  |i.  II,"., 


ises 

OUL' 


0,SLKR:     EXL-l.ATIVK     KKVTHKMA.  I5 

of  which  should  doubtless  be  reckoned  uitl.  (1,1    fv,       <■ 
^-ivun.      In  .u.t,in  one  of  U.e  att.lllr      '    /^  :,:  L:^:^:;-''- 
om,rred  w.thout  purpura.     In  the  ren.arkable  .audi  ,  :!      :^; 

a  few  years  ago,'  in  which  acute  circun,..cribed  o.den.a      . 
hve  generations,  the  gastro-intes.inal  crises  fb  n,  ,;';"' r"'  '". 

the  attacks.     Of  great  interest  in  this  couuectio         ,,  ;:"";:'^ 

tory  ,s  g.ven  un.ier  fusr  /.,  i..  ,vhon,  for  n.ore  than  two        ,    H  T 

have  been  characterised  l>y  iever,  deliriun.  '  •  ^    I'l^''^^^ 

of  great  u.tensity,  but  without  ..kin  le-ion.  "'  '"''' 

U  IS  imssible  that  among  the  cases  of  recurrin.r  ..Htro-inte,!,..,!      • 

.n^r::::r;:::;;:;«:3:::;;'::«;:;;'™ '"'-"• '■-"-■"■^™"- 
.vMoi.  fou,  .,ie„.  „;  ,„:  „j,t  :  r  :  :::,;;t  ;:"'T  "»■»■,"'■ 

markec    trace  a>i  ni  ('•!.:»>  X'^rr    »    1  .  '^  ^^'^^"" 

■ind  Vrrr      Tl  .  '       ^'""^'^  <l"">'tities,  as  in  Cases  HI    IV 

'"  <1  \  III.      1  he  tube  casts  were  hvaline  and  epithcli,!   .,„,!     f 
tamed  bhKHl-corpuscles.     Dropsy  was  present  i,!     :      ''u  ;  .;:^'"  Z 
majority  of  the  cases  the  recoverv  is  comnletP   i.nf  •  '.•'■"''•     ^'"^ 

nephritis  becomes  chronic.  T  e" .  nl  S^o  "."rk"""-"  ^ 
literature  has  been  reported  by  Dr.  I'renH  ;,  ^  Wa  hi  .';r";;  T 
Association  of  American  Pl.vsicians  in   M.,v   J,s<i,      ,    .f'      '  • 

l^ed  thirteen  years,  who  in  March,  ^m:^:^  hlX  ^t  7:  tl  i:;;:;;; 
he  abdomen,  vomiting,  arthritis,  and  purpura.  A  second  at,  iH^^Z  ^ 
.September  and  a  third   attack   in  November  of  the  same  y   " 
"1  cl,    m  addi  lon  to  the  pain  in  the  abdomen,  there  were  hemi      g" 
"^■>.  the  bowels  and  bladder.     In  this  attack  he  was  delirious     „' 
yspiuea  lunl  swelling  of  the  tiu-ehead.     On  December  1       s^:. 

iH  l.ad  recurring  attacks  at  intervals  of  a  month  or  si.v  week       The' 

the  fact  that  he  had  large  hemorrhages  into  the  skin,  which  became  .■ 
j^-|.  and  sloughed.     At  our  meeting  this  y.^^yi!:^^'^!^ 

'Hpl'utis.  with  drop.sy,  albuminuric  retinitis,  increase.l  tension,  an<l  stiff 


ifi. 


•VnnMiciui  Jouniiil  of  Medical 


■ok'iu'c^,  .\|.rii,  iskg 


!!: 


16 


oslek:    exudative   ekythema. 


arteries.  In  tliis  instance  tiie  acute  nephritis  (if  18xy,  associated  with 
the  extensive  erythema  exndativiini,  hiid  tiie  t()un(hUi()n  of  the  present 
chronic  nej)hritis. 

Next  in  order  of  serious  import  is  tlie  hemorrhage  from  tlie  various 
raucous  niemhranes,  wliich  were  present  in  five  of  my  cases.  There  was 
bleeding  from  the  nose  in  three,  in  one  of  whicli  the  nostrils  had  to  he 
j)higged  on  several  occasions.  Case  XI.  had  hemorrhages  from  the 
stomach  and  bowels,  and  coughed  up  l)lood.  Siigjit  luemojitysis  occurred 
in  another  case.  In  three  there  were  hemorrhages  from  the  kidneys 
In  Case  X.  the  gums  were  swollen  and  sp(uigy  and  bled  profusely  in 
many  of  the  attacks.  Hemorrhage  from  the  bowels  is  the  most  com- 
mon, and  occurred  in  thirty  of  the  thirty-nine  in  v.  Dusch  and  Hoche's 
tables,  and  in  thirty-nine  of  the  total  sixty-one  cases.  In  one  case  only 
of  their  list  did  tiie  gums  bleed,  and  in  three  the  sputa  were  bloody; 
in  no  instance,  I  believe,  did  death  occur  directly  as  a  result  of  hemor- 
rhage from  the  raucous  membranes. 

Cardiac  complications  were  not  present  in  my  cases  ;  the  murmur 
in  one  case  (piickly  disap))eared.  Endocarditis  is  rare,  having  occurred 
in  only  two  cases  in  the  total  series.  Pericarditis  occurred  in  three 
cases.  This  is  a  much  smaller  ])erccntage  of  heart  complications 
than  in  the  cases  of  erythema  nodosum  collected  by  Stephen  ^Mac- 
kenzie.  I  have  only  once  seen  cardiac  complications  in  peliosis  rheu- 
matica.  The  case  has  been  reported  by  Dr.  Musser'  who  very  kindly 
took  me  one  day  to  see  the  case.  The  ])atient  had  extensive  peliosis 
rheumatica  with  pericarditis  and  a  gangrenous  slough  on  the  uvula. 

The  respiratory  organs  are  less  frequently  involved.  In  Case  II.  the 
recurring  attacks  of  cough  with  bronchitis  are,  I  believe,  part  of  the 
affection.  The  sputa  always  indicated  bronchitis,  and  at  times  tiie 
cells  of  the  alveolar  epithelium  have  been  unusually  abundant.  The 
cough  was  often  dry,  very  annoying  and  persistent,  and  there  was  once 
or  twice  sneezing.  In  v.  Dusch  and  Hoche's  list  of  thirty-nine  ca.^es 
pleurisy  is  mentioned  twice,  bronchitis  once,  and  pneumonia  twice,  t)oih 
fatal  cases.  In  Case  IX.  of  niy  series  pneumonia  followed  the  disease 
and  ])roved  fatal.  In  this  connection  it  is  interesting  to  note  the  state- 
ment of  Lewin,  who  found  among  seventy  cases  of  erythema  nodosum 
in  the  literature  four  deaths  from  pneumonia. 

The  onset  of  the  attack  nu\y  be  with  a  chill,  as  in  Case  X.  ;  more  fic- 
(piently  the  skin  lesions  are  preceded  by  feelings  of  indisposition  ami 
slight  gastric  disturbance.  The  curious  prodrome,  which  has  recurred 
during  so  many  years  in  Case  I.,  great  c«)Idness  of  the  feet,  I  have  imt 
seen  mentioned.  Fever  is  a  freijuent  accom])animent  of  the  attaeli. 
In  cases  which  have  the  type  of  peliosis  rheuuuitica  the  temperature  may 

1  Tninsiu'tioiis  of  the  Assddiition  of  AiiKTicaii  I'lijsiciniis,  vol.  vi.  p.  JM. 


03LEK:     EXUDATIVE    ERYTHEMA.  jy 

range  from  lOr  to  lO.r,  or  even  higher,  for  several  chvvs  ;  (her.  n.av 
however,  be  the  most  extensive  skin  lesion  without  onvxia  At  tl" .' 
height  of  the  attaek  delirium  may  occur.  .  •     - 

_  Perhaps  the  >uost  extraonlinary  and  distressing  feature  of  the  di.e.se 
IS  the  tendency  to  recur,  which  is  so  „oti<.eal,le  in  all  types  of  exud'.tive 
erythema.     In  C^e  XI.,  in  which   the  disease  has  pirsisti;  f  li   f 

yj.u-s_dur.ng  tl.  hr^  two  years  the  girl  no  sooner  recovered  fi ,.„e 

attack  than  another  l.egan.  In  Case  [.,  the  patient's  life  is,  as  he  ..vs 
a  burden,  owing  to  the  recurrence  every  month  or  two  of  the  .c^v;re 
colic.  ivcie 

he  collected  cases.     The  periarticular  more  often  than  the  intra-ar.icu 
ar  tissues  are  affected,  and  the  chief  part  of  the  swelling  is  often  due 
to  effusion  m  the  ten.lon  sheaths  about  the  joints,  and   as  in  (Ve  II 
the  patient    may  be  able   to  walk   quite   well    with   the  ankles'  much 
swollen. 

The  anatomical  conditions  associated  with  the  visceral  symptoms  are 
not  well  understood,  but   the  changes  in   the  gastro-intcstinal  canal   at 
least,  are  probably  the  counterpart  of  those  which  occur  in  the  ski„ 
namely,  exudation   of  serum,  swelling,   hemorrhages,  and  in  rare  in- 
stances   necrosis.     At   autopsy  hemorrhages    have   been  found  in  the 
internal    org.ns       A    remarkable    case    is   given    by    Silbernumu    in 
Henoch  s  le.sen-.Jt  for  1890.     A  chihl,  aged  ten  years,  was  attacked  on 
December  15,  188/,  with   fever  and  pains  in  the  knees.     ()»  ,he  16th 
there   was   an    outbreak    of    purpura,    with    colic,    Inematemesis,  and 
inekena      After  persisting   lor  three  days   the  symptoms  disa,,peared. 
I  he  attack  recurred   in   January  with  great  severity,  ami  on  the  20th 
^Ist,  and  22(1  there  were  signs  of  an  acute  peritonitis.      The  autopsy 
showed  an  acute  purulent  ].eritoi.itis,  which  had  resulted  from  a  perL- 
ation  at  the  fundus  of  the  stomach.     There  was  no  ul..eration  in  the 
bowels,  but  the  mucosa  was  swollen  and  congested.    There  were  necrotic 
foei  11.  the  stomach  and  intestines,  and  throud.i  were  foun.l  in  son.e  of 
the    bloodvessels.      I„    a    few    instances    necrosis   and   gang,-e„e   have 
occurred  on   the  skin,  as   mentioned  in  connection  with  Dr.  Prentiss's 
case. 

Thc>  outbreak  of  this  type  of  erythema  n.ultifo.-me  during  gonorrhaui 
as  in  Case  V.  of  my  series,  is  interesting  in  con.iection  with  the  etiolo.ry' 
mwe  th.s  ..s  one  of  the  infections  with  which  a  seve.'e  type  of  true  pur- 
pura hemorrhagica  occurs,  an<l  of  which  a  fatal  instance  has  been  .-e- 
corded  by  Patterson.' 

I  I)urposely  refrain  from  discussing  the  relation  of  these  co.idilio,:s  to 
rheumatism,  and  the  questh.n  ,.f  the  infective  character  of  so.ne  form. 


'  ISrilish  Modiciil  Joiinml,  1 


>*S(!,  i. 


■^.11 


v|!  II 


If  :   !:. 


''   ! 


18 


OSLER  :    EXLTDATIVK    EKYTHKMA 


of  erytlieina  exudativiim.  1  linvo  nothing  to  say  which  would  iielp  to 
clear  the  existing  confusion  or  uliicli  is  not  already  better  said  in  jour- 
nals and  monographs  easy  of  access.  My  purpose  in  this  paper  has  "been 
to  call  attention  to  the  importance  of  the  visceral  manifestations  of  the 
disease. 

In  Cases  J  I.  and  X.,  arsenic  appears  to  have  been  beneficial  ;  in  other 
instances  it  did  not  seem  to  do  good. 


would  help  to 
'  said  in  jour- 
>ii|)cr  has  been 
stations  of  tlie 

cial  ;  in  other 


<i^x/v' 


Johns  Hopkins  Hospital  Ilistonml  (<l>ib, 
October  "i   isur. 


JOHN  KEATS 


THE  APOTHECAKY  POET 


BY 


WILLIAM  OSLER 


iiAl.TIMUlU-: 

THE    PRTKDKNWALI)   COMPANY 

1890 


-  j--l-MafeA--' 


^^. 


' 


IF,..  T,,  ,.,„  ,„„„  ,,„,„  ^„„^,,,^   ^^  ^  ^^^^^^  ^^^ 


JOHN  KEATS-TIIE  Al'OTHEaRY  I'OET. 


We  have  the  verv  hio-heaf-  nnfh,,..;,.    t 

discerumeut,  Phito  reonirni7..=  ,.  """"^'o".  with  a  keener 

granted  to  men.     Of  this  divinp  ,.,..  i  ^'I'^test  blessings 

of  the  fourfokl  partitio    .  t^^7T'  ^^^"^^'^  «'- 

kind  is  the  madness  of  t  lose  w    '         ^'^f""^'«"=  "The  third 

winch^  taking  hold  ^:'rHr:a^:^s:i:{td^r' 

i-trnction  of^'posteiS;  u  t  who  h"""'  '"""  '^^^  ^'^^ 
Muses'  madness  in  his  sou^  o.il'l'  "e" V" '°"^' "^^  ^'" 
tl^^'t  he  will  get  into  the  tern  >1  ^h  le,p  ,f  Tt  "l'  \''"'^'^^ 
and  his  poetry  are  not  admitted;  [he  sane  mn, .'     ~    '  ^  ''^' 

marrow  of  the  na:re;f;etr.XT     the  very  pith  and 
is  drawn  bv  many  modern  wH  I  '^"^.'^/''^^'"•<^''  'I'^tmction  than 

the  spirit,  ^f  th^fZn  \ir  ::Jm  ^s';r'  f  ,"^^^  ^'^  '^ 

without  the  Muses'  nT„ln.        '''•'"^''t.     By  the  help  of  art, 

poet  is  a "  lii::  d^^^'^t;;;? "^ '''  'r^^-  ^^^ 

tion,  genius,  facultv,  wlfat  vj    ,^'^^'7'    "^^^  '"^P""- 
allied  to  mudness-he  i.  i       ^  ''^'°^''  ^°  ^^"  ^t,  is 

dell   Holmes   ,;  et  e  S":  •     T  ""r"^''-   ""'''''  '''^■ 
modern  terms,  speakiuioi^i      ^ery  charmingly  in  more 
'  'P^'^^^"S  of  his  own  condition  when  composing 


1 

, 

i*  • 

i 

i 
■    ■ 

i: 

i: 

1 

/■      1 

r 

*   ! 

1 

C     j 

4 

f. 

1  <  1 

J 

* 

il 

f 

n 

! 

f,    1 

.  ^     ! 

1 ; 

K 

j 

! 
i 

s 

n 

i 

jl 

i,    ii 

1     -^ 

^; 

^ 

i 

1  '   1 

i  ■ 

i     ;       1 

^ 

i 

i;1 

,(. 

1 

!  1 

f 

jj 

■1 

^ 

■if 

1^^ 

]'<V  . 

the  Chambered  Nautilus,  "In  writing  the  poem  I  was  filled 
with  a  better  feeling,  the  highest  state  of  mental  exaltation 
and  the  most  crystalline  clairvoyance  that  had  ever  been 
granted  to  me — I  mean  that  lucid  vision  of  one's  thought  and 
all  forms  of  expression  which  will  be  at  once  precise  and 
musiciU,  which  is  the  poet's  special  gift,  however  large  or 
small  in  amount  or  value."  *  To  the  base  mechanical  of  the 
working-day  world,  this  lucid  vision,  this  crystalline  clair- 
voyance and  mental  exaltation  is  indeed  a  madness  workiiinr 
in  the  brain,  a  state  which  he  cannot  understand,  a  Holy  of 
Holies  into  which  he  cannot  enter. 

I. 

When  all  the  circumstances  are  taken  into  account,  the 
English  Parnassus  affords  no  parallel  to  the  career  of  Keats — 
Adonais,  as  we  love  to  call  him — whose  birthday,  one  hundred 
years  ago,  Ave  celebrate  to-day. 

Born  at  the  sign  of  the  "  Swan  and  Hoop,"  Moorgate  Pave- 
ment, the  son  of  the  head  ostler,  his  parentage  and  the  social 
atmosphere  of  his  early  years  conspired  to  produce  an  ordi- 
nary beer-loving,  pugnacious  cockney;  but  instead  there  was 
fashioned  one  of  the  clearest,  sweetest,  and  strongest  singers 
of  the  century,  whose  advent  sets  at  naught  all  laws  of  heredity, 
as  his  development  transcends  all  laws  of  environment. 

Keats'  father  succeeded  to  "Mine  Host  of  the  Swan  and 
Hoop,"  but  died  when  the  poet  was  only  eight  years  old.  His 
grandmother  was  in  comfortable  circumstances,  and  Keats 
was  sent  to  a  school  at  Enfield,  kept  by  the  father  of  Charles 
Cowden  Clarke.  Here  among  other  accomplishments  he 
developed  his  knuckles,  and  received  a  second-hand  introduc- 
tion to  the  Greek  Pantheon.  He  is  described  by  one  of  his 
schoolfellows  as  "  the  pet  prize-fighter  with  terrier  courage," 
but  in  the  last  two  years  at  school  he  studied  hard  and  took 


*  In  a  private  letter  which  is  published  in  a  notice  of  Dr.  Holmes, 
J.H.  H.  Bulletin,  October,  1894. 


if  Dr.  Holmes, 


all  the  prizes.     The  influence  of  the  Tlnrt 

«  ;-ong  unci  for„,utive,  particu    r    ^h      01^^''"  '  "" 

VAun-l.s   Cowdeii,  who  was  an  .   her  i     fh  '^'' /T^^''  «"e, 

On   the  completion  of  hi.  lifteenth  v.  / 
from  school  and  apprenticed  to  V       i  ^  ,   "'"'  ''"'""^'^'1 

Kdnionton.  The  \erm.  of  t le  d  h???'"'  '  ""•«^°"  "* 
'^^Prentice  are  quaint  enou!  "j^"'^^^"^^'"^  '^«  surgeon's 
i^dward  Osier,  dated  1811.  The  suri^  T'  °^  '"^'  ""°^«' 
of  £40,  without  board,  undertook  t^^'  f  consideration 
ttveyearsof  theappren  i  es  If t.        /;'■"  '"'^  '^^""'''^'''^  ^^^ 

fve.  The numbeiy:;:::  ;t  -^^ 

tare  indicates  the  rough  and  iSd  i  ! '"^"^"■^'"^*-'"- 
Sawyers  of  that  date.     T]       o, t?  ^'^  ''  '^^  '^«^ 

"to  haunt  taverns  or  plavl  ou  es  ^tT^T'^"  P™'^"^"!  "«* 
"or  absent  himself  fron/ir  d  n 'I  '^  ^^  '•'  '^'''  ''  '''^^'' 
•'"1-vfuIly,  but  in  all  thi ";;',? -h^^  ^""^^  '^^y  --.-ht 
behave  himself  towards  hi.°lt  ''^'""'^"^  ''Pprentice  he  shall 
said  term."  '  '"^^  "^^'^^^  ^"^  ^^  ^is  during  the 

We  know  but  little  of  the  dav<!  nf  tt.  +  . 
brother  student  said,  "he  wa    'ifdU        fi'^P?"*^''^'^'^-  ^ 
^^•"ti"g  poetry."     Ini814  Tn  tbtf        1     '^"^'  ^'^""^^'  ''l^^-'^y^ 

the  pupil  and  master  ha^a's'ic^rs::^^^^^^^ 

broken  by  mutual  consent     '  °"'''"f '^''  ^^^  the  contract  was 

ing  sentence  in  a  ett^  this  JtW  TbT  '™"  *'^  '°"«- 
passed  between  them:  "I  dn  esi  o ,  h  T'\  '^''^^  "°"^^ 
man  does-our  bodies  evei  v   p    ^  ^  '"''''^  also-everv 

material'd.  Seven  ^^  , Jot  ^'''''-''  ''"^'P^^'^^y  ^^'^^^ 
itself  against  Hamni,'*  ""  "'^  *'"  ^''^"'^  *^^^  ^''-^^'^ 
J^^the^ndof^the  apprenticeship  the  student  "  walked  "  one 


6 

of  theliospitals  for  a  time  before  presenting  himself  at  the  Col- 
lego  of  Surgeons  or  the  Ajiothecary's  Hall.  Keats  went  to 
the,  at  that  time,  U.uteil  Hospitals  of  (Juy's  and  St.  'J'honias 
where  he  studied  during  the  sessions  of  1814-15  and  1815-liJ. 
lie  became  a  dre  ser  at  Guy's  in  the  latter  year  under  Mr. 
Lucas,  and  on  .Iul\  v'o,  1810,  he  i)as-:od  the  Apothecary's  Hall. 
The  details  of  Keats'  life  as  a  medical  student  are  very  scanty. 
In  after  years  one  or  two  of  his  fellow-students  placed  on 
record  their  impressions  of  him.  lie  doesn't  seem  to  have 
been  a  very  brilliant  student.  Poetry  rather  than  surgery 
was  followed  as  a  vocation;  one  of  his  fellow-students  says. 
"all  other  pursuits  were  to  his  mind  mean  and  tame."  Yet 
he  acquired  some  degree  of  technical  skill,  and  performud 
with  credit  the  minor  operations  which  fell  to  tlie  liand 
of  a  dresser.  He  must  have  been  a  fairly  diligent  studunt  to 
have  obtained  even  the  minimum  qualifications  of  the  "Hall" 
before  the  completion  of  his  twenty-first  year.  In  the  Bio- 
graphical History  of  Guy's  Hospital  Dr.  AViiks  states  that  Sir 
Astley  Cooper  took  a  special  interest  in  Keats. 

What  attraction  could  the  career  of  an  apothecary  offer  to  a 
man  already  much  "travelled  in  the  realms  of  gold,"  and  who 
was  capable  at  twenty  of  writing  such  a  sonnet  as  that  on 
Chapman's  Homer  ?  So  far  as  we  know  he  never  practiced  or 
made  any  effort  to  get  established;  and  in  1817  he  abandoned 
the  profession,  apparently  not  without  opposition.  In  a  letter 
to  his  friend  Brown,  dated  September  533d,  1819,  he  says,  "In 
no  poiiod  of  my  life  have  I  acted  with  any  self-will  but  in 
throwing  up  the  apothecary  profession." 

During  the  next  four  years  he  led,  to  use  his  own  words,  "a 
fitful  life,  here  and  there,  no  anchor."  While  a  student  he 
had  made  friends  in  a  literary  circle,  of  which  Leigh  Hunt 
and  Haydon,  the  artist,  were  members,  and  he  had  a  number 
of  intimates — Brown,  Taylor,  Bailey,  Dilke,  and  others— 
among  the  coming  men  in  art  and  science.  From  his  letters 
to  them,  to  his  brother  George  (who  had  emigrated  withjiis 
wife  to  America),  and  to  his  sister  Fanny,  we  glean  glimjises 


an  glinii)st's 


of  his  life  at  this  neriod      in.,  ^ 

fur  as  it  can,  the'  n.  ^  'a,      ^^r"'"'"^••^'"'•''^'  *-'  ^ 
aud  hopes.  '*'*'  '"'  'isj.irations,  thoiiglits, 

II. 

capi^.tiLt::!;;^:^:.^;'^'"'"?^^^'^  ^'^^  ^— the 

teries,  doubts,  without  ,;'„,•  he":?  "V-"""';'"''^''^'  '^^-- 
reason."    The  native  h..P    f  ''^''"•^''""S  after  fact  and 

l-eentertaine;-;::it^;;^;rrt:;i;:t'^  ^'  "''^^ 
soon  sicklied  o'er,  and  he  lapsed  o  at  .^o  J""" 
remunerative  work  was  concerned  A  ,  1  ,  ^''  '"  ""^ 
Mrs.  Abey,  the  wife  of  the  tr  s  e  of  tlT  r^'-  """"'  "'^'^ 
cloned  his  conduct  with  the  wo  ds  J  ^  '^'^  ^  ^^'''^e,  con^ 
indolent,  tlmt  tJiey  would  ever.  i   ^  ''^''''  ''"'"''  ^^^r 

then."    In  a  letter        Lb  otheMr'  '^'h''  ""^  '^^"^  '" 
Here  is  his  confession:   "^ tord J?      '  "^''*  ""•'• 

p;:^i^-tsts^ 

but  as  I  am*  I  must  call  it  lu.ines  T      ;?        T^r'' 

piness  and  is  a  rare  inst'iuoP  n?!] '  '  '  i'  ^'^'^ ''^  the  only  hup- 
overpowering  the  2ul  '  '^''  '^^^''"^^='°^  «^  the  body 

*  Eapecially  as  I  have  a  black-eye. 


8 

us  with  u  visit."     Fatal  to  encourage  in  an  active  man  uf 
afTiiirs,  this   dreamy  stnto,  tiiiji   passive  existence,  favors  in 
"bards  of  passion  and  of  mirth  "  the  devohii)ment  of  a  fruit- 
ful  mental   attitude.     The   dreamer   spins   from    his   "own 
inwards  his  own  airy  citadel";  and  us  the  spider  needs  but 
few  jjoints  of  leaves  and  twiirs  from  wliieli  to  l)ogin  liis  airy 
circuit,  so,  Keats  says,  "nnui  sliould  be  content  with  as  few 
points  to  tip  with  the  fine  web  of  his  soul,  and  weave  a  tapestrv 
empyrean,  full  of  symbols  for  his  spiritual  eye,  of  softness  for 
his  spiritual  touch,  of  space  for  his  wanderings,  of  distinct- 
ness for  his  luxury."     All  tlie  while  Keats  was  "  buddiu" 
patiently,"  feeling  his  powers  expand,  and  with  the  "viewless 
wings  Toesy  "   tailing  ever  larger  flights.     An  absorption  in 
ideals,  a  yearning  passion,  for  the  beautiful,  was,  he  says,  his 
master-passion.     .Matthew  Arnold  remarks  it  was  with  him 
"an  intellectual  and  spiritual  i)assion.     It  is 'connecti'il  and 
nuide  one'  as  Keats  declares  that  in  his  case  it  was  'with  the 
ambition  of  the  intellect.'     It  is,  as  he  again  says,  the  niightv 
abstract  Idea  of  Beauty  in  all  things."     Listen  to  one  or  two 
striking  passages  from  his  letters:  "This  morning  J\)etry 
has  conquered,— I  have  relapsed  into  those  abstractions  wliich 
are  my  only  life."     «  I  feel  more  and  more  every  day,  as  my 
imagination   strengthens,   that  I  do  not  live  in   this  world 
alone,  but  in  a  thousand  worlds.     Xo  sooner  am  I  alone  than 
shapes  of  epic  greatness  are  stationed  round  me,  and  serve  my 
spirit  the  office  which  is  .qnivalent  to  :i  King's  body-guard. 
Then    'Tragedy   witli    seepter'd   pall    comes  sweeping   hv.'" 
"What  the  imagination  seizes  as  beuuty  must  be  truth,    the 
expression  iu  jn-ose  of  his  ever  memorable  lines, 

"Beauty  is  truth,  truth  beauty,— that  is  all 
Ye  know  on  Earth,  and  all  ye  need  to  know." 


III. 

Keats'  first  ])ublished  work,  a  small  volume  of  poems  issued 
in  1817,  contained  the  verses  written  while  he  was  a  student 


he  "viewless 


D 

und  before  he  had  ubandonud  tl.e  i.iof,.ssi„n     \vn  u 

tion  of  one  or  two  sn.uU  iu^xvh  it   ol  i    T.        ''  ^''';"^^''- 

The  Honnet  on    Char.nuu  •/iT  """*'""  "^  '"'f'-'- 

tion.     In    1818   am.e,in..I    ;,;.  , '"''"^"'''^   l'"<^"">f  tl'e  collec- 

these  reviews  are  believ  .1  (.1?  1     ('';  'tvroo,/.    im,,,,,,,, 
a  belief  fostered  b,  the  ju.uitXrtli^l!;:";  ^^^'''^  ^•^'''^•^- 
" -Tis  «tran«,.  th„  „,i„,i.  tl^u  very  Aery  particle 
^''-''''etusclf  be  snuffed  out  hyanVr?S:."' 

-i-l  thai.  h^'IuS^i  ^:  i^  ^j^';;i--«'-tne.of  his 
the  Hrst  place,  he  had  .  c l       , '  "'''^  '^''""■^'-     ^'^ 

and  the  value  of  his  work.     The  ,     f  oe  h.  1  "  ^'°"""' 

the   most  remarkable  ever  J  h  ,     1     /         ^""""' ^"' ^^ 

judgment.     He  felt    h-li    I        '  ."*""'  '"'  "^^"   '"^''^1 
ihS  i\  ^  f'>iindations  were  "too  s.nulv" 

.luuu   ur  a  ,\oung    man   in   trans  tion  "■'     «Th^ 
imagination  of  a  boy  is  healthv  nn,l  fi,.  .     '""'"O"  •         J  he 

*  ,.„  '"'  ^'^""^•''it,  the  character  undeoideil    Hio 

way  of  life  uncertain,  the  ambition  thick-sightec       1      c^^^ 
oeeds  .nwkHhness  and  all  the  thousand  bitters'.!-      tC^ 

as  t  e  (^«.r  ,r/^  /;,,,„„  j,„t,  -.^  .^j^^  ^^^^^  incongruous  ieTs 
n  the  most  uncouth  language,"  but  the  poem\        n     « 

iK'tlir;::i;ir  ^""  ^"^^^'^  ^-^  ^^^-^^  ^-«  ^^-  ^ 

rankled  deeply  lu  his  over-sensitive  heart,  but  after  the  first 


'  I 


10 

pangs  he  appears  to  have  accepted  tlie  .castigation  in  a  truly 
philosophic  way.     In  a  letter  to  his  friend  Hersey,  dated  Oct. 
9th,  1818,  he  writes,  "  Praise  or  blame  has  but  a  momentary 
effect  on  the  man  whose  love  of  beauty  in  the  abstract  makes 
him  a  severe  critic   in  his   own    works.     My  own  domestic 
criticism  has  given  me  pain  without  comparison  beyond  what 
Blackwood  ov  the  Quarterly  could  possibly  inflict,— and  also 
when   I    feel   I  am   right,   no  external  praise  can  give  me 
such  a  glow  as  my  own  solitary  reperception  and  ratitication 
of  what  is  fine.     J.  S.  is  perfectly  right  in  regard  to  the  slip- 
shod Endymion.     That  it  is  so  is  no  fault  of  mine.     No!— 
though  it  may  sound  a  little  paradoxical,  it  is  as  good  as  I 
had  power  to  make  it— by  myself."     And  he  adds,  "  I  will 
write  independently,-!  have  written  independently  tvithout 
judgment.     I   may  write   independently,  and   with  judgment 
hereafter.     The  Genius  of  Poetry  must  work   out  its  own 
salvation  in  a  man."   A  young  man  of  twenty-three  who  could 
write  this,  whatever  else  he  possessed,  had  the  mens  suna,  and 
could  not  be  killed  by  a  dozen  reviews. 

In  June  1820  appeared  Keats'  third  work,  "Lamia,  IsabcUa, 
The  Eve  of  St.  Agnes,  and  other  poems;'  which  placed  him  in 
the  first  rank  of  English  writers.  I  will  quote  briefly  the 
criticisms  of  two  masters. 

"No  one  else  in  English  poetry  save  Shakespeare,"  says 
Matthew  Arnold,  "has  in  expression  quite  the  fascinating 
facility  of  Keats,  his  perfection  of  loveliness.  'Ithink,'  he  said 
humbly,  '  I  shall  be  among  the  English  poets  after  my  death.' 
He  is;  he  is  with  Shakespeare." 

Lowell,  speaking  of  his  wonderful  power  in  the  choice  of 
words,  says,  "i[en's  thoughts  and  opinions  are  in  a  great 
degree  the  vassals  of  him  who  invents  a  new  phrase  or  reapplies 
an  old  one.  The  thought  or  feeling  a  thousand  times  repeated 
becomes  his  at  last  who  utters  it  best.  ...  As  soon  as  we 
have  discovered  the  word  for  our  joy  or  our  sorrow  we  are  no 
longer  its  serfs,  but  its  lords.  We  reward  the  discoverer  of  an 
anesthetic  for  the  body  and  make  him  a  member  of  all  the 


11 

Houghton's  Life  and  Leffpf,  °'^^^   *^  ''^'^   ^^^rd 

almost  unfathoniably  deep  irtbf.lw,'  P°''^'^  (^'^^"gh 
sense  and  humoi  etc    of  tl      !!'    t"^  "f  •  '^^°"-  "^''^^'-'"Ji"^ 

I  an.  tempted  to'  Zn^L  p  l^f  ci;:if  ^f"  ''  fl^'^'^'^' 
than  any  poet  since."  ^'"'''' '^"'^^^  ^^  Poetic  faculties, 

IV. 

Very  few  indications  of  his  r)rofp=!<!;nnni  +„  •   • 
fo.n.d  in  Keats'  letters ;  fewer'st  n       «,    p ^^  ^f  ''■  '' 
to  his  studies,  he  says,  in  one  of  the  e-ir1v  J         I,   ^^'^^^'""^ 
George  Felton  Mathew),  " fa  lif^irlZllsTl  ^    ''' ''''''' '' 
from  soft  Lvdian  airs  ''     n,,,.       .V    /  ''''"'"  "^^  ^^^rnly 

1  son  1  ^y^^^^  ^"s.  During  the  four  years  from  1  qi  7  m 
18^0  he  made  fitful  efforts  to  bestir  himself  into  .ntin  ? 
on  several  occasions  his  thoughts  tnrne  w  i  i!  "'  '"'^ 
In  a  letter  to  h.s  brother,  wrilt^  in  "ebr  trfsi  0^""'"^• 
"  I  liave  been  at  different  times  turning iHn^'  \  ]  '''^'' 
I  shoum  go  to  Edinburgh  and  IZ^  ZS:'f' " 
afraid  I  should  not  take  kindly  to  it-  I  -2  f  -'';"'"> '  I  '''^ 
take  fees-and  vet  I  should    ilL  V    V  "'^  ^  ^""'^^  "°<^ 

writing  poems  ind  ttg  '.  tl  m\,t  L'  \e'  If  "?  ^^^'^^  "^- 
Review  shambles  "  In  1S1%  11  ?  .  ,  ^'^-'^'«^'»  on  the 
"  Were  T  fn    /  i       ,  ^  """^^^  *''  ^^^  friend  Reynolds 

\\  eie  I  to  study  physic,  or  rather  medicine  -iff-iin  T  f  ^ 
would  not  make  the  least  difference  in  m  nl'f^  '  I  V^ 
mind  is  in  its  infancy  a  bias  is  ^ZZy^C^^t  it  ''^ 
acquire  more  strength,  a  bias  becomes  n  b  '"  1]!':  thlt 
he  IS  glad  he  had  not  given  away  his  medical  ios'i;^^^^^^^ 

attack  of  tr^^^^  ^^^  ^-J^Tf  ^^  *'^  '"' 
of  three  things-oV  a    lealt  two    s     .^    a  ''  ""'^ '^'^^'^ 


i  1 

t     1 

V 

i 

: 

'} 

I 

'     1 

1 

1   ! 
^    i 

;■ 

,'  i 

!j 

I 

: 

:i  i 

■|  ' 

,'   1 
u, 
;)'  1 

Hi 

i: 

: 

:    li 

', 

I. 

*^ 


12 

in  a  letter  to  Miss  Jeffreys,  he  spoke  of  voyaging  to  and  from 
India  for  a  few  years,  but  in  June,  1819,  he  tells  his  sister 
that  he  has  given  up  the  idea  of  an  Indiaman,  and  that  he 
"  was  preparing  to  enquire  for  a  situation  with  an  apothecary." 
Allusions  to  or  analogies  drawn  from  medical  subjects  are  rare 
in  his  letters.  In  one  place,  in  writing  from  Devonshire,  he 
says,  "  When  I  think  of  AVordsworth's  sonnet,  '  Vanguard  of 
Liberty !  Ye  men  of  KeH^ ! '  the  degraded  I'ace  about  me  are 
puh'is  ipecac  sitnplex — a  strong  dose." 

He  played  a  medical  prank  on  his  friend  Brown,  who  had 
let  his  house  to  a  man  named  Xathan  Benjamin.  The  water 
which  furnished  the  house  was  in  a  tank  lined  with  lime, 
which  impregnated  the  water  unpleasantly.  Keats  wrote  the 
following  short  note  to  Brown  : 

Sir  .—By  drinking  your  damn'd  tank  water  I  have  got  the  gravel, 
What  reparation  can  you  make  to  me  and  my  family? 

Nathan  Benjamin, 

Brown  accordingly  surprised  his  tenant  with  the  following 
answer: 

Sir  :—l  cannot  ofifer  you  any  ren^uneration  until  your  gravel  shall 
have  formed  itself  into  a  stone,  when  I  will  cut  you  with  pleasure. 

C.  Brown. 

In  a  letter  to  James  Rice  he  tells  one  of  the  best  maternal 
impression  stories  extant :  "  Would  you  like  a  true  story  ? 
There  was  a  man  and  his  wife  who,  being  to  go  a  long  jour- 
ney on  foot,  in  the  course  of  their  travels  came  to  a  river 
which  rolled  knee-deep  over  the  pebbles.  In  these  cases  the 
man  generally  pulls  off  his  shoes  and  stockings  and  carries 
the  woman  over  on  his  back.  This  man  did  so.  And  his 
wife  being  pregnant,  and  troubled,  as  in  such  cases  is  very 
common,  with  strange  longings,  took  the  strangest  that  ever 
was  heard  of.  Seeing  her  husband's  foot,  a  handsome  one 
enough,  looked  very  clean  and  tempting  in  the  clear  water, 
on  their  arrival  at  the  other  bank  she  earnestly  demanded  a 
bit  of  it.     He  being  an  affectionate  fellow,  and  fearing  for 


13 

the  comeliness  of  his  child,  gave  her  a  bit  M-hich  he  cut  off 
with  h,3  clasp-knife  Not  satisfied,  she  asked  fo  a^  he' 
morsel  Supposing  there  might  be  t.vins,  he  gave  her  a  si  ce 
moi^.    Not  yet  contented,  she  craved  another  pie  e' You 

Take  t'haT'"  ^'^  ^^^\' --nU  yon  .isl.  me  to  kill  mys^r? 
Take  that,  upon  which  he  stabbed  her  with  the  knife  cu 
her  open,  and  found  three  children  in  her  belly:  two  of  then 
very  comfortable  with  their  mouths  shut,  tl/th  nl  1       " 
eyes  and  mouth  stark  staring  wide  open     'Whn  wli 
tho^jght  it  r  cried  the  widowe^  and  JC iied  Dis   oZ      ''''' 
The  estate  of  Keats'  mother  was  greatly  involved,  and  it 

Abbey.     H,s  books  were  not  successful,  and  having  no  love 
for  th:   .,anmry  hack  work   in   literature,  he  was  lar^el 

^''  ^-  r  lett  ^  'T' '' '' '''''''''  ^--  ^^^^^ 

win"    f  *^^'f*^^f  the  receipt  of  money  is  acknowledged 
Who  could  resist  a  charming  borrower  who  could  thus  wifte 
"I  am  your  debtor;   I  must  ever  remain  .0;  nor  do  I  .ih   0 
be  clear  of  my  i-ational  debt;   there  is  a  comfort  in  throwin' 
oneself  on  the  charity  of  one's  frienda-'tis  like  tbe  albaS 
eeping  on  its  wings.    I  will  be  to  you  wine  in  the  ce  lai-     nd 
the  more  modestly,  or  rather,  indolently  I  retire  into  the 
^.ckward  bin,  the  mor.  Falerne  will  I  be  at  the  drinking" 
We   must   remember,   however,   that   Keats   had   reasonable 
expectations.     He  says  to  Haydon,  December  23d    181      <I 
lZ7f'   ll  ™o«ey  whieh  may  enable  me  to  study  and  to 

try  to  be  "  o'"  T  ""'  '""■"  ^^  ^^'"^^  ^"^^^^^  wisdom  to 
try  to  be  "correct  in  money  matters  and  to  have  in  my  desk  " 
as  he  says  "the  chronicles  of  them  to  refer  to  and  0  kno'w 
my  worldly  non-estate." 

To  the  worries  of  uncertain  health  and  greatly  embarrassed 
affairs  there  were  added,  in  the  summer  of  1819,  the  pangs, 
one  can  hardly  say  of  disprized,  but  certainly  of  hopeless  love 
AVri  ing  to  his  friend  Eeynolds,  May  3d,  1818,  in  comparing 
ife  to  a  large  mansion  of  many  apartments,  he  says  pathetic- 
ally that  he  could  onl^  describe  two;   the  first,  Infant  or 


r  ff 


I  l-'i 


I; 


ii  I 


14 
rhons-htless  Chamber,  in  which  we  remain  as  long  as  we  do 

m  which  at  hrst  we  become  intoxicated  with  the  light  f„d 
a  mosphere  unti    it  gradually  darkens  and  we  see  not  w 
the  exit  and  we  feel  the  "burden  of  the  mystery."    For  1 
nends  he  hopes  the  third  Chamber  of  Life  may  be  filled  w   h 
the  wine  of  love  and  the  bread  of  friendship.     Poor  fellow  r 
JJithin  a  year  the  younger  Aphrodite,  in  the  shape  of  Fan  ; 
Bawne  beckoned  to  him  from  the  door  of  this  third  cW 
be  .     Through  her  came  no  peace  to  his  soul,  and  the  Muses' 
nspu-ation  was  displaced  by  a  passion  which  rocked  him  .s 
be  "winds  rock   the  ravens  on   high  "-by  Plato's  four  1 
variety  of  madness,  which  brought  him  sorrow     id  "1 
eyed  despair.''     The  publication  of  Keats' letters  to  F^l 
Brawne  can  be  justified;  it  must  also  be  regretted.     While 
there  are  some  letters  which  we  should  be  loth  to  miss,  there 
ai    0  hers  the  publication  of  which  have  wronged  his  m:mory 
Whether  of  a  young  poet  as  Keats,  or  of  an  old  philosopher 
as  Swift,  such  maudlin  cooings  and  despairing  wails  should 
be  ruled  out  of  court  with  the  writings  of  paranoiacs. 

V. 

of?si?'i'^f''''^'if.'"°'""'i^^^"""^l^l^-  I"  the  winter 
of  1817-18  he  nursed  his  brother  Tom  with  the  same  disease. 
In  the  spring  they  spent  several  months  together  in  Devon- 
shire, which  Keats  compares  to  Lydia  Languish,  "  very  enter- 

moi.tuie.  In  the  summer  he  took  a  trip  through  Scotland 
and  in  the  Is  and  of  Mull  caught  a  cold,  which  settled  in  lii^ 
hir;L  r  '""  !;■  '^f'"^  I'^^-erness,  August  6th,  he  speaks  of 
his  throat  as  in  "a  fair  way  of  getting  quite  well."     On  his 

Le  wHt.r<o''"^'''1  ^'  ""''''  ''  ''  '^»''^"^'  ^"^  ^^  September 
he  writes  "lam  confined  by  Sawrey's  mandate  in  the  house 
now,  and  have  as  yet  only  gone  out  in  fear  of  the  damp  night." 

brother  lorn,  who  died  in  December.     From  this  time  the 


16 

ttroat  keep.,  ,..  i„  thilZl  Jr^,„^tf„nt'  "-'"^ 
January  letters.  In  a  Febriru-v  1  ff  '/^'''^'^^  ^*  ^^  '^gain  in 
that  the  sore  throat  haslj  h^  ^i  . ;;':  ?T  ''  "^'^ 

twelvemonth.  In  June  -uhI  T  l  i  "'  "^'^^^^  fo^'  »*-'="-ly  a 
the  summer  spent  inX  tl  J'^i  ^ :::f:,t.r  T""  ^"* 
hnn  good,  and  in  September  he  vW  es  to  oi  .  H^  1"' '^^'^ 
that  be  had  got  rid  of  hi.  "h,     \  °^  '"'  ^''^•^"^s 

"^  tji-i.  lui  or  'lis  "hiiuntins:  sore  thronf"     t  i 
laid  stress  upon  this  mrfinni....  f    ^  tnioat.      J  hjiye 

little  .uestioi  th.;f;nr;;,^f:?^-,^-— 1^^  ^"t 

as  IS  common  enough,  with  this  localize  ion      v  f "' 

a  year  there  had   been  constant  ev^^^^^^^^ 
brother,  and  under  conditions,  in^CZs^liTT'  '"' 
favorable  to  infectio  -      Th.  -i  ^"^™"snue  at  least,  most 

in  the  autun^f^^isi/t'rrr  f '^1^^^''^'=^^^^ 
Through  the  summer  of  islslh:";^,  :  ^r^^^^"""^" 
to  an  irritable  state  of  health  an-irt  frnn,7i  A  ^*'^^^'^"ces 
""«tting  him  for  ment.l  "iS  ^  ^^Int^llT'r 
and  healthy  and  lasting  orga.  i  tion  f  1  "  ,  ^  f  ^  ^ ''^e 
strong  as  an  ox's    so  n,  tn  ,  ^  '^"'^  '^"^S«  as 

years.     But  I  feel  my  bodv  too  we.l    /!  "^^'*^ 

health,  but  on  December  '>nfh  I,.  '^^  '  ,  ,^''''''^  '"  g°°'l 
lest  the  weather  IZ^aJ^  mVC  1  '?'"  "'^^'^'"'"^ 
or  cold  continually  threatois  Le.''  '  '  "''  '"  "'^■"•^'^" 

On  February  3d  the  smoulderin<r  fi^s  brok-P  nnf  f,  , 
had  been  exposed  in  a  sta^-e  ride  n  a  atttknf  '  ^^  ^''  ''' 
From  this  date  we  can  tnic  u  "  ettf  th  l^r't'",'- 
progress  of  the  disease.  In  Apr  H  'Nhv  H  .  '"^''^"^holy 
b^ame  less  p^nounced,  but  i!^;  C  JtLl  ^SSr 
bihty  and  weakness,  he  was  able  to  direct  the  publi^lt;:"  ^ 


i'[ 


16 

his  third  little  .volnme  of  poems.     On  June  22d  he  had  a 
re  urn  of  the  spitting  of  blood,  which  lasted  several  dl 
The  serious  nature  of  the  disease  was  by  this  time  evident  to 
both  the  patient  and  his  physicians.     He  acknowledges    ht 
It  will  be  a  long,  tedious  affair,  and  that  a  winter  f n  1     ' 
may  be  necessary.     "'Tis  not  yet  consumption,"  he  wri   I 
Fanny  Keats    "but  it  would  be  were  I  t^  remain  in  t 
climate  all  the  winter."    This,  too,  was  a  time  of  tern    e 
mental  distress,  as  he  became  madiy  jealous  of  his  best  friei  d 

t.ll    f!r?;     ^^'  ^'^^'''  "^  '^^'  P'''''^  t«  Fanny  Brawne 
tell  of  the  "damned  moments"  of  one  who  "dotes  yet  do     ts 
suspects,  yet  fondly  loves."  "onots, 

Preparations  were  made  for  his  journey  to  Italy,  which  he 
speaks  of  "as  marching  up  to  a  battery."    He  sail  d  fo 
Naples,  which  was  reached  after  a  tedious  voyage  about  th 
end  of  October.  Severn,  the  artist,  accompanied  li^Z 
given  CAflanhc  Monthly,  April,  18G3)  a  touching  account  of 
he  last  months  of  his  friend's  life.  Kealizing  fufly  the  1"! 
lessness  of  his  condition,  like  many  a  brave  man  in  a    inX 
plight  he  wished  to  take  his  life.     Severn  states,  "In  a  1    U e 
basket  of  medicines  I  had  bought  at  Gravesend  at  h^s  re  u 
there  was  a  bottle  of  laudanum,  and  this  I  afterwards  found 
was   destined   by  him  'to  close  his  mortal  career,' when  ,0 
hope  was  left   and  prevent  a  long,  lingering  death,  fo    n^ 
poor  sake.     When   the  dismal   time  came,   and   Sir  Jani  I 
Clark  was  unable  to  encounter  Keats'  pen;trating  look  .S 
eager  demand,  he  insisted  on  having  the  bottle,  which  I     ad 
already  put  away.     Then  came  the  most  touching  scenes    He 
now  explained  to  me  the  exact  procedure  of  his  gradual  dissolu! 
tion  enumerated  my  deprivations  and  toils,  and  dwelt  upon 
he  danger  to  my  life,  and  certainly  to  my  fortunes,  from  my 
continued  attendance  upon  him.     One  whole  day  was  speil 
in  earnest  representations  of  this  sort,  to  which,  at  the  same 
time  that  they  wrung  my  heart  to  hear  and  his  to  uttor,  I  was 
obliged  to  oppose  a  firm  resistance.     On  the  second  day  his 


ir 

tender  appeal  turned  to  deannir  ;„    n  .u 

imagination  and  bursth.!  E^'*         ^'  ^'""'^^  ^^^  ^^ent 

care  throughout  the  !L;:r:;  ,^^f '^f ,  Jl^ '^^--^uous 
sumptives,  Keats  had  no.ie  of  the  vZ  »m  '", -"^"^  '''^■ 
them  hopefully  to  the  very  ..te   of  ^^  ""'  ''^'''^'  '""''''^ 

desperate  was  his  state.  "  f  f  "  V  T'\  ^^'  '^'"^^  ^«^ 
ing  over  me."  "  Who!  will  tl  '  T''^'  "  '^'  ^^^versgrow- 
end  ? "     On  Februa  v  il  P^^^^humous  life  come  to  an 

scribed  on  his'^I^^rnt't^e;^  '^-^  ^°  '^^  -" 

"  Here  lies  one  whose  name  was  writ  i„  water  " 
On  February  27th  he  passed  away  quietlv  in  ^ 

All  lovers  of  poetry  cheri.h  kH'^      '^'''''"  '  ''^'•'"^• 
of  the  verse  with  w  Ich  h    h  ,t    !'  ^"-'T  for  the  splendor 
is  also  that  deep  pathos  it  a  i  e        Tf  ^n  H  ''""'""•   '"'"^ 

his  brhi^Geo::::;"''^'^ ''''''  ''^^  ^^  --^^  m  ms  to 

"X'jlSr"''  '  ''•'''  '^'^  '^""  «"^  ««rthly  mould, 
Yet  shall  my  spirit  lofty  converse  hold 

With  after  times." 


*  Under  similar  circumstances  onp  nf  fv,^         .,     . 

loving  of  men  whom  it  has  been  Lylo?to''an''    '"'  "°^^ 

successful,  and  when  he  realized  fuUv^L        ?       ,        ^'''^  '^°'^ 
awaited  him,  took  the  lauXnnn!     -.k     I    f'"""'' ''''8"""e  ^^^th 

been  provided.    In  such  1  c.T    T     ''^'^  fo'"  months  he  had 

kindly  words  with  whSh  Bur  on'  7     ''.  ^- '"''  ^""  "°*  ^^^^  ^he 

suicide?    ''wlo  kiwshow  h.         T  ^"'  ''''''^^^*^'^  ««'^"°"  on 
isiiows  now  ne  mav  br  tfrnvtaA')    ti  •    ,  • 

are;  charity  will  judge  and  hop  Ihe Tes"  Goiiy'-Tr'^' 
us  all  1"  ^  ^''  ^°"  be  merciful  unto 


18 

finfwUh''Kea?sr^°  ''"''  *°  J«'"  ^^^^  "g-tle  band,"  a„d 
tnul  with  Keats  "a  grave  among  the  eternal,"  has  expressed 
the  world's  sorrow  in  his  noble  elegy.     I  quote  in  olT 
his  less  well-known  fragment :  '  conclusion 

"  Here  lieth  one  whose  name  was  writ  on  water  " 
But.  ere  the  breath  that  cckl  erase  it  blew 

iJeath,  in  remorse  for  that  fell  slaughter 
Death,  the  ii-.-iortalizin"  winter,  Hew' 
Athwart  the  stream,— and  time's  r.rintlpss  tnrr^„^ 

A  scroll  of  crystal,  blazoning  the  nam"  "'"'  ^^'^' 

Of  Adonais.  .  .  . 


le  band,"  and 
has  expressed 
in  conclusion 


rrent  grew 


LOOIOA   IMEDICA. 


[TUI    MftlTIM 


t;AL    J'iV'RMit 


671 


m 


1 
f 

,t 
11- 
I. 

t 

ir 

e 

s- 

18 

>k 
nd 
lis 

^h 
i(> 
d 


go  to  th<'  BurRcrifS  of  the  mcdiciil   otlicfrs.     I'rintiiiK,  8ta- 
tioncry,  and  salary  of  clerk  an-  alone  taken  out  if  tlie  doctor's 

Sueli  a  scheme  as  this  will  Rive  tlie  poor  all  the  advantiiRPS 
of  an  ordinary  private  patient.  The  scheme  is  HUtlieienlly 
coinpreliensive  to  provide  for  the  medical  relief  of  all  the 
working  elasses  between  those  who  nn-  in  receipt  of  parochial 
relief  and  those  who  are  able  to  pay  the  lowest  i)rivate  fees  in 
any  district.  ,         ,  ,,       ^        ,. 

Tliere  are  undoubtedly  a  large  number  of  tlio  strugRling 
working  classes  in  which  the  weekly  payment  of  sulmcrip- 
tions  to  a  medical  t)ene(it  is  the  f,iily  method  by  which  thtJ 
doctor  gets  paid  at  all.  A  certiun  .lass  of  these  peotWc;  are 
not  to  b<'  trusted  for  a  i)rivate  account  of  even  a  few  shillings. 
The  provident  scheme  is,  therefore,  favourable  to  the  profes- 
sion. ,      ,       ,         i     •      1 

It  is  tlie  well-to-do  working  man  I'lio  li  ts  been  trained  up 
in  the  custom  of  getting  the  doctor's  aid  for  next  to  nothing, 
and  who  has  yet  to  be  taught  that  he  will  be  expected  to  con- 
tribute according  to  liis  means.  .  . 

A  comparatively  simple  organisation  of  easy  Bupervision— 
with  an  attractive  scheme -should  enable  the  medical  profes- 
sion in  each  town  and  district  to  remedy  the  present  abuses 
of  the  club  system.  It  is  necessary,  however,  for  each  section 
of  the  profession— be  it  in  town  or  country— to  sliow  a  united 
front,  and  make  a  determined  stand,  otherwise  a  few  weak- 
kneed  individuals  might  cause  the  w I lole  profession  to  lose 
the  advantages  of  combined  action. 


ARCH^OLOtilCA   MEDICA. 

XXVII.—"  DOVER'S  ANCIENT  PHYSICIANS'  LEGACY." 
In  the  Bulletin  of  the  Johns  Hopldiu  Hospital,  vol.  vii,  p.  i. 
Dr.  Osier  has  given  an  interesting  account  of  "  Ihoma.. 
Dover  (of  Dover's  Powder),  Physician  and  Buccaneer.  In 
this  paper  Dr.  Osier  speaks  of  the  confusion  that  exists  as 
regards  the  various  editions  of  Dover's  Ancient  Vhmicians 
Leaacu.  The  Dictionary  of  National  Bioyraphy  states  that  the 
first  edition  of  this  book  was  published  in  1733.  Dr.  Osier 
points  out  that  this  is  an  error,  and  states  "  that  it  is  due  to 
the  fact  that  in  this  year  appeared  an  edition  of  the  7>eyacy 
not  stated  on  the  title-page  to  be  a  second  edition  1  his  is 
the  earliest  copy  in  the  library  of  the  Royal  iMedical  and 
Chirurgical  Society  and  in  the  Radclifle  Library."  Dr.  ()sler 
probably  was  unable  to  examine  both  these  copies  and  so 
clear  up  tlie  diilicuUy.  The  1 733  edition  in  the  Royal  Medical 
and  Chmirgical  Society's  Library  bears  internal  evidence  that 
it  is  not  tlie  first  edition,  as  on  p.  181  there  is  a  heading 
"  Addenda  :  The  substance  of  several  letters  sent  to  the 
Author  since  the  publication  of  the  last  edition  ;  with  further 
remarks."  There  is  a  copy  of  this  book  also  in  the  library  of 
the  Royal  College  of  Surgeons.  The  Radclifl'e  1733  book  is 
difFerent  from  that  of  the  Royal  Medical  and  Chirurgical 
Society,  and  is  evidently  the  second  edition,  as  it  does  not 
contain  the  addenda  referred  to  above,  but  leaves  oil  at  the 
end  of  the  "  Hospital  Surgeon."  This  clears  up  the  chiej 
difficulty  as  regards  the  early  editions.  The  second  and 
third  have  nothing  on  their  title  pages  to  show  the  edition  ; 
the  fourth  and  fifth,  also  published  in  1733.  aif'  so  called  on 

their  titles.  ,    .  ^       ,,■,.•,       i.  j  +, 

Dover  took  his  M.B.  at  Cambridge,  but  did  not  proceed  to 
the  degree  of  M.D.  Dr.  Osier  states  that  "  on  the  title  page 
of  the  first  edition,  however,  the  letters  M.D.  occur  after  his 
name."  This  is  a  mistake;  the  1732  edition  has  M.B.,  the 
second  and  third  have  Thomas  Dovar,  M.D.  ^h«  two  last- 
named  editions  are  both  "  printed  for  the  relict  of  the  late  K. 
Bradly  F.R.S.,"  and  the  1)  is  in  all  probability  a  misprint. 
From  the  fourth  to  the  eighth  editions  the  author  s  name  is 

spelt  Dover.  '.  ^  j  •     iv     1  *„„ 

Although  additional  matter  was  incorporated  m  the  later 
editions,  Dover  does  not  seem  to  have  remodelled  his  book. 
In  the  first  edition  there  is  a  postscript  headed.  Having 
—  it*"d  the  following  letter  from  Anthonu  Balam  Esq.  in 
Great  Russell  Street,  winch  I  designed  to  have  inserted  wheni 
was  speaking  of  Quicksilver,  I  shall  give  it  my  Readers  in  this 
place  "  This  matter  appears  in  the  same  form  in  all  the  sub- 
aeqnent  editions,  and  was  never  incorporated  in  its  proper 
place. 


LOGICA   MEDICA. 


r   THt  ««iTi»ii       Aff 


1 

f 

t 

II- 

1. 
t 

ff 

e 

8- 
18 

ck 
nd 
tis 

d 


go  to  till'  surgcrit's  ..{  tlif   n»i'<lifiil   ollici'ia.      I'riiitiiiK,  stn- 
I'DiU'ry,  and  salary  ol  clerk  an;  alone  takun  out  of  tlu'  doctor's 

Such  a  Bchcmo  as  thic  will  give  tlif  iioor  all  tlit>  advantageH 
of  an  ordinary  private  piiticiit.  Tin-  scheme  in  rtudiciently 
coinprehenBive  to  provide  for  the  medical  relief  of  all  the 
working  classcH  between  thoKe  who  an-  in  receipt  of  parochial 
relief  and  those  who  are  able  to  jiay  the  lowetit  private  fees  in 
any  district. 

There  are  undoubtedly  a  large  number  of  tlni  struggling 
working  claHses  in  which  the  weekly  piiyment  of  Hubscrip- 
tions  to  a  medical  henelit  is  the  only  nu-thod  by  which  the 
doctor  g<'tH  paid  at  all.  A  certain  class  of  these  peo^tlo  ar« 
not  to  be  trusted  for  a  private  account  of  even  a  few  shillinKs. 
Tlie  provident  scheme  is,  therefore,  favourable  to  the  pn  i  s- 
sion. 

It  is  tlie  well-to-do  working  man  who  has  been  trained  up 
in  the  custom  of  getting  the  doctor's  aid  tor  next  to  nothing, 
and  who  has  yet  to  be  taught  that  he  will  be  expected  to  con- 
tribute according  to  his  means.  _  , 

A  comparatively  simple  organisation  of  easy  supervision— 
with  an  attractive  scheme-  should  enable  the  mediial  profes- 
sion in  each  town  and  district  to  remedy  the  present  abuses 
of  the  club  system.  It  is  necessary,  liowever,  for  each  section 
of  the  profession— be  it  in  town  or  country— to  show  a  united 
front,  and  make  a  determined  stand,  otherwise  a  few  weak- 
kneed  individuals  might  cause  the  whole  profession  to  lose 
the  advantages  of  combined  action. 


ARCHiEOLOGICA  MEDICA. 

\ XVII.— "DOVER'S  ANCIKNT  PHYSICIANS'  LEGACY." 
In  the  Bulletin  of  the  Johns  Jlopkins  Honpital,  vol.  vii,  p.  I, 
Dr.  Osier  has  given  an  interesting  account  of  "Thomas 
Dover  (of  Dover's  Powder),  Physician  and  iUiccaneer."  In 
this  paper  Dr.  Osier  speaks  of  tlie  confusion  that  exists  as 

J  ...  • ^j:t;„„„    „f     /)„„«,.'«     Anr.iimt    I'hunicians' 


'BBU^V  JO  -I'SPJO  J'H  JO  (SSU[0  !)S1) 

I'lSjuM  I'  i'q  o')  'ipiAiuoaJO  'imidHoii   sjioiuuds   '"n  Jo  ^^n 
-uody  '!ii-Ji[.3i[M  -tl  •Jj\[  pa^ujoddu  sBq  «,)p,)A\s  }o  iJuixf  ;inx 


•pjMH  puB  puooas  ain  .loi  ui  in 
■jsnf  srionip,)  .i.Hj  SB  '^pjui  ^[p.tBt[  si  siq'j  ;nq  1 3{0oq  oqj  pajuiid 
pHif  ^(piMji  -ji  rf;i)iai[)  JO  iO![ajaiii}t  su  s>(oo[  mqSiH'jB.iinV 
■'lo^fll  I'liH  i(j.io.vis,j;vi!T  's.ioijsnqnd  luuiSi.io'oin'oj  }[OBq 
-HfoS  ,)Ai;i(  p(uoiis  j.)AO(j  Srjuo  .i.);b(  eq^  .loj  g.'uq')  ptiB  'uorjips 
13.i!(  oq'Huo.ij.t.tqsnqnd'pw.WHip  v  Aq  ponssi  uaoq  .)ABq  p[u6iis 
suonipj    p'JJdqumuun    oAq  aq'j  ^iii(;  snojino  .u)q^B.i  si   ^ 

•oruBs  .)!{')  siuBaw.i  uocjBoipap 
oi[}  JO  Sinp.ioAi  .»in  inq  ..'^wqoa,,  o%  paaj^pi  si  .".unor,, 
auiBU  •)i[%  suoiiip.)  'jso'pq  aq?  uj;  -suoqip.!  p.mn  p'uB  puooas 
aq;  o]  uonB.upap  on  sBq  AfpBag  -Ji  a^Bi  ai[;  jo  !),iqaa  aqT 
■A«'^««1H  JO  hi[.i  'XiB.iX  Ui{Of  0^  pOJBjipjp  ai  :[U(.iq  z£li  aq^, 
•uoi-jipa  auiBs  aq'j  o'+  s./aBcl  ojiii  jo  sias  om  .to 


^^>  / 


i  %  ^     I 


'"''"  "''""^'  'f"'Pi'''l  l'i^U,n..al  VI.,, 
•I'tnuiiry,  /,s,'*,;_ 


THOMAS  DUVKR 


(OP    |)ovK,'s    f„vvi,.    M 


PHYSICIAN  AND  3UCCA 


NEER 


ftY 


^ILLJAM  OSLER 


BAI  TIMORK 
THE    FUIEDK.VWAI.I.   ...MI-ANV 

ISOd 


h^yt^  A 


i^-«^«.        fi7'9<^^^€^ 


C^^*^^ 


^  ^U^^ 


^    /W'7V.*«^*^<'A-.   ^'^^^♦.^^-•'^v 


/y^z/^  '/■^ 


fiU-ff'W*** 


•     -p*^^*^    ^«*.^-^- 


y^ 


■^. 


CFrom  ne  Johns  napkin.  Ho.pUal  nuUetin.  N' 


O'  5s,  .lanuary,  ifSM.j 


THOMAS  DOVER   Ar  r   ,.    ^ 

i-HlSJClAA  AND  BUCCAXEER 


.^'^ ''^"'Thomas  Browne  remark^?  in  f),    t/    ,  • 
iniquity  of  oblivion  blind! v   oil    h^^'^^'''''^'^'^^^''"--  "The 
with  the  inen,o.-v  of  men      tho^   Hi   '7  ^'^^^^  -'^    '^^I« 
ftuitj."    Thus  it  happen      h     t)  '^  '' '''''''  ''  P^^- 

has  drifted  into  our  mode      1  "''  ^''''^  ^^''^  ^o^tor, 

-y  of  entering  the  ^^^l     'S^Sf  ^ '^^'^^  ^^o  which 

bj  Mithridutes,  many  would^refe   ol   "''         '^"''  '^^"^^''^^'^ 
ous  immortality  on  a  nowdP,-  ^  ''*"  °'^^^"0"'  even  to  continu- 

Buccaneer,  third  in  command  onrnf  .1  '  "°'''''  ^'^e 

and  president  of  the  Cou  ^T  tl  e  A.V'""?;^^  ""^"•^' 
privateers  of  the  ancient  .md  1.  *^f,  ^"'^^  '"'d  Duchess,- 
eoverer  of  Alexande    S    Jd^     ^       '  ''''  ''  ^^•-^"J'-dis- 

iB  spite  of  more  end  i"  Him  '"^"'"'^  '^"''"^°"  ^''■"^°<^)' 
forgotten.  '^  ''''""*  «"  o'"'  g^'atitude,  has  been 

was  born  in  Waruickshire  aCo  t  ^^^Jn^^J- "^  ''''''  '^'^  ^^ 
of  medicine  of  Cambridge  on  tl;,'*  ^'  ''"''  ''  ^''^^^^'^^ov 
the  Aaenae  Can,,H^;  Z^^.:^'''^  ^\  "-  -thor  of 
on  the  roll  of  the  grad  nte  A  V  V?"'' ^^"'^  "^*  '''^' 
settled  in  Bristol,  and  la-t^^^  ''^"'^  his  degree  he 

-ei-chants  in  a  p/'ivateelS  ;e%e^ft Ln  "^n'^'n"' '"!'''  ^^"^^ 
to  England  he  resumed  m-acSc     at  Bn'  .    '     T'  ^"^'"^'^ 

-ber  of  patients  he  salsr^^ti^^'d^^dS^^ 


•'mftiiaaijittMiKiaLtiawWB 


epideinic  of  the  fever,  he  must  have  obtained  the  coulidence 
of  the  inhabitants  of  that  city."  In  17^1  he  settled  in  Lon- 
don and  was  admitted  a  Licentiate  of  the  IJoyal  College  of 
Physicians.  He  resided  in  Cecil  Street,  .Strand,  but  in  the 
latter  part  of  1728  he  removed  to  Gloucestershire,  where  he 
lived  for  four  or  five  years,  when  he  tinallv  settled  in  T 


lOnd 


at  flrst  in  Lombard  Street,  and  afterward 


on. 


s  in  Arundel  Street. 


Strand,  where  he  died  probably  in  the  latter  juirt  of  1741  or  tht 
of  17-12.     ::^ssentially  the  same  details  are  given  bv 


beginning 

Dr.  ]Vorman  ^Nfoore  i,i  the  Dictionary  of  Xational  Biograpliy. 

In  his  work  "The  Ancient  I'hysician's  Legacy"  he  oftL'u 
speaks  with  veneration  of  Sydenham  as  his  IMaster;  and  in 
his  description  of  the  snuill-pox  he  says,  "whilst  I  lived  with 
Dr.  Sydenham,"  so  that  he  was  probably  a  house  pupil  of  the 
great  physician,  who  was  at  the  height  of  his  fame  at  the  very 
time  we  may  suppose  Dover  to  have  been  a  student  of  medi- 
cine. On  the  title-page  of  the  first  edition  of  the  "Legacy," 
1732,  he  speaks  of  forty-nine  years  of  practice,  so  that  he 
probably  took  his  degree  in  1GS3.  Apparently  he  never  pro- 
ceeded to  a  doctor's  degree,  since  he  speaks  of  himself  as  a 
"poor  Bachelor  of  physic."  On  the  title-page  of  the  first 
edition,  however,  the  letters  M.  D.  occur  after  his  name. 

We  know  really  nothing  of  Dover's  life  until  he  appears  as 
one  of  the  promoters  of  a  privateering  expedition  to  the  South 
Seas  in  1708.  In  this  he  was  associated  with  a  group  of 
Bristol  merchants,  among  whom  were  Alderman  Bachelor  and 
Sir  John  Hawkins.  Two  ships,  the  Dnke  and  the  Duvhafts, 
were  fitted  out  with  great  care.  Dover  went  as  third  in  com- 
mand, being  styled  Captaii\  Dover,  and  as  owner  of  a  very 
considerable  share  of  both  vessels,  he  was  president  of  the 
Council,  and  had  a  double  voice  in  the  deliberations.  The 
days  of  the  buccaneers  were  almost  numbered,  but  there  was 
in  Bristol  at  this  time  one-  of  the  last  and  one  of  the  most 
famous  of  ,.■  old  South  Sea  captains,  William  Dampier,  a 
man  who  knew  more  of  the  Spanish  Main  and  of  the  Pacific 
than  any  one  living.     He  had  returned  recently  from  a  disas- 


he  confidence 
?ttled  iu  Ldii- 
al  Collegi'  of 
1,  but  in  the 
ire,  where  he 
edin  London, 
•iindel  fStrcL't, 
of  1741ortlie 
i  ;ire  given  Ijy 
il  Biogniplij. 
cy  "  he  often 
ister;  and  in 
b  I  lived  with 
I  pupil  of  the 
lie  lit  the  very 
ent  of  medi- 
he  "  Legiicy," 
e,  so  tluit  he 
le  never  pro- 
himself  as  a 
;  of  the  first 
3  name, 
lie  appeai-s  as 
tothe^outh 
a  group  of 
Bachelor  and 
the  DuvhfS!<, 
ihird  iu  corn- 
ier of  a  very 
ident  of  the 
ations.  The 
)ut  there  was 
of  the  most 
Danipier,  a 
f  the  I'acilic 
from  a  disas- 


i»  »-l.ich  words  OI.„,os  Ki„„3,.,  .,"  "'  '* »' *'  "~ 

ot  Hit-  voyaj-e  is  toM  (,,.  f',,,,!-,,,,  ,,.     ,      °"-     iHeiwrralive 

The  expedition  u-.,.         i  '  -^'  ^'""don,  i;io 

Captain  Kog^,,.  """  '»  ""«  tolil  i„  (h,  „„,j^  ^^ 

off  to  go  on  shore,  t^:  g  '  71"^;?'^  '"^^^-  ^^^^^  -^ 
the  ship.  Asitgrewdark%veoter;  d!  •  ^7'  '''^''''  '''"^ 
some  were  of  the  opinion  was  from  n  °  ''  °"  ^'^"'•«'  ^^J^i'^h 
cleutlytoolargeforthat  nut  7  "  '""*' ^"^  ^t  was  evi- 
boat,  firing  o.u-  c.uart t  ;  ^ .::;  T'''  ?•  ''^"^^'  ^«  ^^-ect  o^r 
-d  fore  shrouds',  that  our  ^.i^^Lv^fl  ''''  ''  ""'  "-- 
to  leeward  of  the  island.     Our  Cf  ,"''  "'  ^^'^  ''^^^^  ^'^''^n 

two  in  the  morning,  l,avi,.ttnt  r;'"V'''°'"''^  ^'°^""  ^^bout 
ashore  wheti  withini  I  a^  ^  !  jT  ""  '"  ^'^^'"^^  ^^^^  ^i.^ht 
of  so  well,  as  it  now  beg^;  to  1  on  T  ^'"'  '"''^  ^^^^  ^°t 
that  the  light  which  w  hid  1^  J%"'^^'^'  '^"  ^-"»-d 
therefore  prepared  our  ship   for   '  ^''"^  '^''  ^^ore,  and 

-.£ht  proceed  from  so^!^^ ^^^^^^  -'PPosing  it 
must  either  fight  or  want  water  Till''-  '"''''''  ''^'''^'  "'^ 
sion,  as  we  afterwards  found  •  I'ose  f  -n  "  '"'^  ^PP^'ehen- 

Passed  in  our  imacrination  fn  !•  '  ''"'  P"*^''  »'^^»'  who 
Frenchmen,  or  a  ^^Tj  :^^:r'':  '""^^^"'  ^'  '^^^  '>f 
strange  notions  some  of  o       ,     '  ''  ''  "'''"^^^^'  ^^^^t 

light;  yet  it  served    o  sho     th S  t   ™'"'"""^  ^^^'^"^  ^^is 
enabled  us  to  guess  how  0  I  n^^^^^^^^^^^  -"'  ^P^^'ts,  and 

really  were  enemies  on  the  ishnd  ''  '  "^  '"^°  ^^'^'"'^ 


6 


! 
i  i 


"While  uiuler  these  apprehensions  we  stood  to  the  back  of 
the  isLuid  in  order  to  fall  in  witli  the  southerly  Avii.d  till  we 
were  past  the  island;  then  we  stood  bacii  for  it  again,  and  ran 
cl.we  aboard  the  land  that  begins  to  form  its  N.  1'].  side.  'J'iie 
ilaws  came  heavily  off  the  land,  and  we  were  forced  to  i-eef  our 
to])-sails  when  we  oi)ened  the  middle  bay,  where  we  ex])ecteil 
to  find  oui  enemy,  but  aU  was  clear  and  no  sliips  either  there 
or  in  the  other  bay  near  the  N.  E.  end.  These  are  the  only 
bays  in  which  ships  can  ride  that  come  here  for  refreshnu'iits, 
the  middle  one  being  the  best.  We  now  conjectured  that 
there  had  been  shij)S  here,  but  that  they  had  gone  away  on 
seeing  us." 

"About  noon  of  the  2nd  of  February  we  sent  our  yawl  on 
shore,  in  which  was  Captain  Dover,  Mr.  Fry,  and  six  men,  all 
armed;  and  in  the  meantime  we  and  the  Duchess  kept  turn- 
ing in,  and  such  heavy  squalls  came  off  the  laud  that  we  Jiad 
to  Itt  fly  our  top-sail  sheets,  keeping  all  hands  to  stand  by  our 
sails,  lest  the  winds  should  blow  them  away.  These  flaws 
proceed  from  the  land,  which  is  very  high  in  the  middle  of 
the  island;  but  when  they  passed  by  we  had  little  or  no  wind. 
As  our  yawl  did  not  return,  we  sent  the  pinnace  well  armed  to 
see  what  had  occasioned  the  yawl  to  stay,  being  ;..  :•  u'd  there 
might  be  a  Spanish  garrison  on  the  island,  who  ij'ht  have 
seized  her  and  our  men.  Even  the  pinnace  delayc'.  returning, 
on  which  Me  put  u})  the  signal  for  her  to  come  back,  when  she 
soon  came  off  with  abundance  of  cray-iish,  bringing  als )  a 
man  clothed  in  goat  skins,  who  seemed  wilder  than  the  orig- 
inal owners  of  his  apparel.  His  name  was  Alexander  SeK-i7'k, 
a  Scotsman,  who  had  been  left  here  by  Captain  JStradliug  of 
the  Cinque-Ports,  and  had  lived  alone  on  the  island  for  four 
years  and  four  months.     Cupt.  Dampier*  told  me  he  had 

♦Selkirk  had  been  eailinfr  master  under  Captain  Dampier  in  liis 
expedition  which  left  in  May,  1703,  and  luid  l.ieen  put  ashore  on  the 
island  at  his  own  request.  Dampier's  expedition  was  unsnccessfiil. 
and  "the  merchants  were  so  sensil)le  of  his  want  of  conduct,  that 
they  resolved  never  to  trust  him  any  more  v.ith  a  comman  '  " 


J;-    y,  but  o„l,  two  eunu^o    ,    ho,  :.  H    '-T'  '''''^  «'"'P« 
f«"'>'l   to  he  fS]>ani.sh,  unci   th    v  f  ''"  ''''""''  ^^'"^-l^  he 

which  they  (ireclu(  hi  n        m       '^'""  '""^''^'^  f'-o'u  tlien,    on 

^jeyheenVenehi:::;  t::r''rt^^-''^  "^2 

chose  rather  to  r„n  the  ri«k  ovh,!;,''''  to  thon.;  hut 
f''^>l  '"to  the  hand,  of  tJ,e  sl  i'""\°"  ^^^^' '^'-hI  thau 
^vould  ether  put  him  to  .iea  or  m'l'',  '  '"^^"^^"''^''  "'*-T 
"""es.     The  Spaniards  had         'e  /  h  ""J  '  ^^'"'^^  '"  ^'-"> 

;ere  and  can.e  so  near  hin,      . u  ,  ^'^'  "'^"^  ^'"^^ 

for  ti.ey  not  only  shot  at  hiz^  h      pu 'u    n"'' ^^'^  ''  ^^^^I-' 
where  he  climbed  upa  tree  . U   .  f    t  ^   '""'  "'^"  ^^'^  ^^oods 

-ulo  water  and  kl./ed  s:::'.     '   .tf  et   ^^''7'  ""'^  ''  ^^-'- 
(liscoverinir  ],i„,."  ^oat.,  ^et  went  away  without 

"ile  told  us  he  was  l)orn  in  T 
Scotland,  and  was  bred  a  sailor  f,"^"",  '•"  ^^'"  "^"""^^  ^^  Fife, 
of  his  being  left  there  wlTii";"    "  '■''''''•     ''^^^  --ou 

1'"^,  which,  together  wit  teSh^  ','''!  ^^^^'^=''"  ^^''-i" 
^■•^t  rather  willing  to  stav  e  1^'"'^"  ?-'^'  "'"^^'  '»""  ^^ 
'^"'^  ^^''^^'^ut  last  he  was'in  i„  ,  '? '^''"^■""^  "^  the  ship; 
would  not  receive  him.     He  5  ^"  '^"'^  ««"^'  th«  eapta  u 

wood  and  water,  when  two  oL'r/'  "'^  ^'^'^^^^  '-^ore  t 
jx  n^onths,  the  ship  bein'  cha  el  T  '  ''''  "P«"  ^^  ^^^ 

«-  ships;  but  the  Oin.iu^PoiStj  r^^'  'f  ^^^  '--eh  South 
at  which  time  he  was  le  t.  [fe  I  d  -H  /•  "'^  '"°'^'  ^'^^'"  ««• 
l>e^l'ling,  with  a  firelock  and  so  ,  ]  ^""^  ^"^  ^'°''^««  ""d 

*«'-"■<>.  =^  ^nife,  a  kettle,  i";,;?;'"'  '^''''  ^•■"^^^^'  «'»- 
h'^  mathematical  instrument       ir  ""  "^^''''"  '^«°'^«'  "ud 

viJed  for  his  sustena  e  n  '^V^'^^'-^^d  hin.self  and  pro- 

-'o  to  bear  up  against  m":^;;^: -'J^V''^^"^^  "'"^^ 
ami  was  sore  distressed  at  bein^ii    ,    ''  '""''^  ''»'^t  months, 

Pl--     lie  built  lun,s  1    two  i      /^""'^  "^  "'^'^^  '^  ^^-^'ate 

-ith  long  grass  and  lii.ed  w       :"'/•"""; ^?,  ''''''  «^-tched 

needed  then,  with  his  gun    o   on    t  l"'"''       ''"°  '''''  ''  '^^ 

»      *o  long  as  lii«  powder  lasted,  which 


I 

;  I- 


v;ts  only  about,  ii  iiouii  1  iit  llrst.  WIhmi  all  tiuH  was  sjht'I  lie 
procured  tire  '.)v  riililiip j;  two  stick.s  of  piiiiciito  woe  ■  'ii-x'tiur. 
Ill'  slept,  ill  lii.s  larger  liiit.  ami  cooked  lii,-  vidua.,  iii  li.e 
siiialler,  wliicii  was  at.  soine  distaiu'i'.  and  eiiiployed  Ip  Ji.seit" 
ill  readiiii;,  ])rayiIll,^  and  .  iiii;iiijj;  jit-aljiis,  so  tiiat  (le  said  lie  was 
a  lieller  ('liristiaii  diiriiiij;  In  >  solitiKir  fU.tu  lie  (^ver  had  been 
before,  and  tiiaii,  as  he  uas  afraid,  iu'  .voiiid  ever  Ik;  a^^•lin." 
'"At  tirst.  he  never  ate  but.  when  rest.rair.ed  \-\  liiiiif^ei-,  ]>iirt,ly 
from  jj^rief,  and  partly  for  want,  of  bread  aiu  salt.  Neither 
did  In-  (lien  go  to  bed  till  lie  could  walcii  no  longer,  flu- 
}>iiiu;i((.'  wood  serving  him  both  for  lire  and  candle,  a.'^  it. 
buriu!  vers  I'lear  and  ri-freshed  him  by  its  fragrant,  smell. 
lie  migli!  iia-.i  bad  lisK  uioiigb,  but  wtuild  not.  eat.  them  for 
want  of  N.:'..  as  t.iioy  (>ccasione(l  a  looseness;  except,  eraytish, 
wliieh  are  :>,'  iarge  H:^  lolisters  and  are  very  good.  These  he 
aoiiK'times  lioiled,  and  at.  other  times  broiled,  as  he  did  his 
goaf's  llesh.  of  which  he  made  good  broth,  for  they  arc  not  so 
rank  as  01! r  goats.  Having  kept  an  account,  he  w.ud  he  had 
killed  r>()()  goals  while  on  the  island,  besides  having  caught  as 
many  more,  which  he  marked  on  the  ear  and  let  tl  em  go. 
AVIion  his  powder  failed  he  ran  down  the  goafs  by  s|H'ed  of 
fool  ;  for  his  inotle  of  living  with  continual  exercise  of  walk- 
ing and  riinning  cleared  him  of  all  gross  humours,  so  that  lie 
could  run  with  wonderful  swiftness  throngh  the  woods  and 
up  the  hills  and  rocks,  as  we  experienced  in  catching  goats 
for  us.  We  had  a  bull-dog,  wliitdi  we  sent  along  with  several 
of  our  nimblest  runners  to  lielj)  in  catching  the  goats,  but  he 
outstripped  our  dog  and  men,  caught  the  goats,  and  brought 
them  to  us  on  his  back.  On  one  occasion  his  agility  in  pur- 
suing a  goat  lu'arly  cost  him  his  life;  as  while  jiursiiing  it 
■with  great  eagerness  he  caught  hold  of  it  on  the  brink  of  a 
jirecipice,  of  which  he  was  not  aware,  being  concealed  by 
bushes,  so  that  he  fell  with  the  goat  down  the  precipii'e  to  a 
great  depth,  and  was  so  bruised  and  stunned  by  the  fall  that 
he  lay  senseless,  as  he  supposed,  for  twenty-four  hours,  and 
•when  he  recovered  liis  senses  found  the  goat  dead  uiuh  r  him. 


lis  >|u'ti(  lie 
II'  *  'ii;^'L'ttUT. 
iiu..'  Ill  iiic 
yoil  Itifisc'lf 
•  siiid  lie  Wiis 

T    lliul     l)lM'll 

iigin-,  jiarMy 
II."      NfitluT 

Joiiger,  tlx; 
audio,  us  it, 
,n'.inl,  siiu'll. 
it.  tlicm  for 
|)t.  criivlisli, 
'I'lu'so  lie 

ho  (lid  his 
y  lire  not  so 
jiiul  ho  hiul 
?  Oiiiii^ht  an 
si.  tl:('in  go, 
by  wpi'od  of 
so  of  walk- 
1,  so  Miaf.  ho 

woods  and 
diiiig  goats 
ivith  sovoriil 
mis,  hut,  he 
111!  l)rought 
lity  ill  piir- 
jmrsiiiiig  it 

brink  of  a 
)nc'eaied  ])y 
■oipico  to  a 
10  fall  that 

hours,  and 
undi  r  him. 


II 


>•  was  M 


<'''^''""l,  an, I  ,,,,,1,1 


"■"  ■^'•iir.vly  aid,.  ( 


■II 

hr,.a,i 


n,i| 


"  I'l-aul   I 


(ur 


''  •■'''""'  111    l,.l,ir(),    , 

In  (h 


mil 


'>;-;:un  r 


"     'lis    i,|,f 


NlioiM 


an, I 


sal 


'  ivhsii  i 


or  ii 


nicn, 
liad  al 


'"l'«-  "hiVli   |,a,|   I 


)iriiji,.|. 


"■^  inral  uril 


'"  davf 


'I  niiie 


'I'i'ii 
'|>roa,| 


-I'asDii 


"■"•I  liud  n,,„. 
'■^•"i'>iin,ian,.oof  ,.",'i 

«^'HSO,U.dhisf,„„|,,i,|,    J, 


'»f(|   li 


over 

diaLM' 


saiiic  wiMi  ,; 


n-  r 


KTl. 

f^<-'V,Tal 
fniiii    I 


nl 


aiiiai 


I'll  if 


by  ( 

aiti'cs 

lie  cal 


""""«•''  "'iUioiit 
l'l''n(y  „J'  irn„,i 


iiplaiii    I) 


of 
-bai 


"iijtior's 


^'I'oiin, 


fo 


■'^"  ii.^|)i'oi,-s  of  h|. 


ra.  11 


l"'l'l"'i-,  an, I  I 


las   ;i 


r  ox 
II 


polling 


»iii,|  and 


l"'l'|"T<'all, 


I'i'nrnii),  u  i 
(illc  (1, 


-pal 


Ik 


:tvor. 


"Js,  and 
'"■'•''  i.s  the 


I!    S,)()||    w,, 


'■nrinL''  "ri 


Jn 


ho  \v,),)i|f 


an, I 


I'o  ,)|1(   |,i,^  ^1 


'^  ,^ 


rijHv 


'  '""/''/M/,  „lii,.| 


"'■  /oiiiul 
good 


1    U'a,-: 


wcaiu, 


iH'Mll 


'""'s  an, I  ()(j 


«o  hard  IJiiti.  i 


iiiri'i 


"■'•  'dotlics  ) 


voni,.M,.t.,  and  it 


'f  ran  a 


'"  •''"''■'  "idioul,  (I 


'y  ''"unin'r 


could  Wt 


woar  thoiii. 


!ir  si) 


was  soiii,.  I 


»)ii( 


'"t'«,  as  his  I 


'"if  af(,.r  h 


''Vorywl),..n 


U'ln, 


uitJ 


L'  OailK' 


^■^'''  Hwollod   when  i 


(o 


'lis  feet 
1011 1  incoii- 


•After  he  h:ul 


lie  lirsi 


"■I  bof,ji-o  h( 


anil 


'«wl  himself  will 
^■'"i  'lio.lafoof  I 


/fol'  l»ottor  of  ! 


''ogan  I 


0 


1  <.'iir villi;-  I 


'1I.-5   Illol, 


res  id 


OlU'o. 


I'cnig  ill,,, 


'ii-<  nan 
■o,  and 


'"loliolv  Ik 


had 


^^t  first  I 


lie  oil  (1,^. 
'"-'  l-inie  ,jf  ] 


''i-od  ther 


i«  H-its  mil,. I 


""iiii'tinio.- 

S,   Ir.ged 

lis  sol  it 


le; 


arv 


'I  di,- 


wliich  had 


'^  "1  groat  I 


iiiinli 


■d  with 


watered  at  the  isl 


«•'"■  <>"   .slior,.   fn„i,   ,s| 


■rs  f, 


'•"'«  'I'Hl  nils,  which 


■"'II  .some  of  ,_.a,.i 


when  ho  w 


foeil 


"Iff  Hiom  witi 


uid.     'I' 
Wiisloej),  uliiol 


lio  ral,- 


S'»  (anio  that  (I 


'  ;-^'>iifs  II, ..si 


1  oldii;-(.|i   I 


"V   flial    ha,| 
"•''"•(■d  his  fV,., 


Ii  Sjieeios 
»'<)o<lo,l  and 


an, I 


I'  .so  that  1 


liini  toolic-rish  tl 


ololi 


lolivoivil 
*'■  Jii.s  diver 
!iis  (.als: 


''^y   "«'''l    fo    li,.   |„,j,,^    ,,; 


f( 


I'll  from  tl 
•«ion  w,)u  1,1  al 


lie  ral 


II 


ni  in 


linu 


'■  :ii.so  tamed 


I'aiiy  „f  tl„.,„  I 
l""idiv,ls.  and 


I  OS 

x'came 


10  oals 


«»ine  kid,.: 


'I'.s  youth—fur  I 
iit  length  to  00 


«","""  in- the  fav,u-,',fl 


"',?an,l  dance  with  th 


soon 
and 


10  Mas  1 


to 


"■  'I'lilo  oasv  in  I 


ii'inorall  t| 


K'u-  onlv  II 


'I'ovid 


^■'ict'  lUld  tl 


10  iiioon 


"I'ly  years  of 


■'11  and 
lie  vig.jr  of 


a'l-O' 


When  h 


IS  clothes 


ii.s  min,l 


v^^'iionces  of  his  solitud 


L'  came 


Ji'Hl  u  cup  of  goat  sk 


Wore  worn  out  ] 


of  th 


''''^'""e,  cut  out  with  his  knife 


■--  '  -Muouc  iie  made  hi 

,' •;^';:'^f!'^'-^^^ogethe; 


yi^  himself  a  coat 


with  til 


tongs 


KmK>'^ms 


'.  i 


:i: 


10 

Subsequently  the  expedition  sacked  the  two  cities  of  Guaiii- 
quil,  in  tlie  ussiuilt  on  which  Dover  led  the  van.  They  took 
several  i)rizes  and  cruised  about  the  coast  from  Peru  to  Cali- 
fornia waiting  for  treasure  ships.  Of  one  of  the  largest  prizes, 
which  they  named  the  Barhehr,  after  the  Bristol  aldernuui 
doubtless,  Dover  took  command  as  chief  captain.  Tliey  then 
sailed  across  the  Pacific  to  Batavia,  where  they  refitted,  and 
in  October,  1710,  sailed  for  England,  which  was   reached  in 

1711. 

Captain  Thomas  Dover  returned  from  the  South  Seas  a 
wealthy  man;  the  expedition  had  been  unusually  successful, 
having  realized  the  enormous  sum  of  £170,000.  To  Dover, 
who  is  stated  to  have  been  the  owner  of  a  very  considerable 
part  of  both  ships,  fell  a  considerable  share  of  the  spoils. 
Alexander  Selkirk  as  mate  received  £.'^00  prize  money. 

Harris  (  Voi/affcs,  etc.)  makes  the  following  comments  on  the 
voyage:  "It  has  been  universally  allowed  by  such  as  are 
proper  judges  of  such  expeditions  that  there  never  was  any 
voyage  of  this  nature  so  happily  adjusted,  so  well  provided  in 
all  respects,  or  in  which  the  accidents  that  usually  happen  iu 
Privateers  were  so  effectually  guarded  against."  This  he 
attributes  to  the  aliilities  of  the  gentlemen  of  Bristol,  ami 
remarks  that  it  was  owing  to  this  expedition  that  the  spirit 
of  privateering  in  the  South  Seas  was  not  totally  lost  in  Kng- 
land.  The  large  sums  realized  had  evidently  made  an  endur- 
ing impression,  and  Harris  adds,  "  I  might,  perhaps,  ^,o  too 
far  should  I  assert  that  this  voyage  gave  rise  to  the  South  Sea 
Company,  but  this  much  I  can  safely  say,  that  the  success  of 
this  voyage  was  what  the  jiatrons  of  that  Company  chietly 
insisted  upon  in  their  defence,  when  the  plan  of  it  was  attacked 
as  insufficient  and  chimerical."' 

In  171:!  Dover  must  have  been  fifty  years  of  age,  and  quite 
ready  to  enjoy  a  period  of  leisure.  Where  he  settled  or  what 
he  did  we  do  not  know,  but  it  is  certain  that  three  years  such 
as  he  had  spent  at  sea  were  no  preparation  for  practice.  I'os- 
siblv  he  travelled,  and  in    the  introduction  to  the  Anrient 


ies  of  fiuuiii- 
,  They  took 
I'eni  to  Cali- 
argest  prizes, 
tol  iilderiiKiu 
Tliey  thuu 
retitted,  and 
s   readied  in 

5outh  Seas  a 
ly  successful, 
.     To  Dover, 

considerable 
if  the  spoils, 
loney. 
inientsou  the 

such  as  are 
3ver  was  any 
1  provided  in 
lly  happen  in 
t.''  This  he 
'  Bristol,  and 
uit  the  spirit 

lost  in  Kng- 
ide  an  endur- 
rhaps,  ^;o  too 
:he  South  Sea 
he  success  of 
iipany  chielly 
;  was  attacked 

ge,  and  (piite 
ttled  or  what 
•ee  years  such 
ractice.      I'os- 

)  the  Ancient 


4\ 


11 

Phi/nkinn's  Legani  he  scoff.  .,f  fi      . 

"'"'-<■  -^I'^'aking.  and  des  ribt!  t  ''  '^:"'^'''"">'  '^"^  ^'^^  the 
f'HT.  hi.nseif.  If,  ,,.f  .  '  r^f  '''  "'  ^^'''''^^'  ''*•'  '^'^J  I'fen 
-'^-•f  the  g,o..,:.a^'i;:  '';:;;-"%  t-^  in.  wide  kno^wl 
'""cessary  to  nnike  an  acconin  M  V'^''.'  '^  travelling  bo 
t'"^^  \  '"-  travelled  n^  S  n  '^^Z'  r'^T"'-^  ""  ^^'•>-- 
lintainpnt  together."  '''"  Physicians  of  (;,.eut 

^»  17:31, as  nienfioucd  bv  ^\^u^v  i, 
«f  the  Uo,,i  College  o  pIvS" '"""  "^^^'^'^  ^^'^-tiate 
•j'"^''!-!  a  nnm  at  that  time  o  ,';'•'  ''"'^li'i^'^tio.i  which 
;^-'!--ter.  rtisdou;fuCt."r"''^'"'^^'--""i 
.'"'"^  '"  '-mion ;  at  any  rate  heVt  t  s7.  I  7'""""^  '''  ^'"« 
'"  ''■--tershire  in  the  yea  "  ^  .  ^^^  f^o  "^  '^'  ^^''-^ 
'■'^■■^^•^  ^vhud,  he  mentions  in  his  bool-  '.        "^""'^  "^  ^^'^ 

'"■'•'"""^'"t   «ottlen,ent   dates   frorn       ^/^^'^  l''^'''^^''     "'^ 

t'HM.seuf  .,nicksHve;,ho  ir^f'Jn'  '"''""  ^^''''^tures  ou 
\  i-e  lost  three  paU^^ti  ;  t  e  p^T  ^"^ '^  ^''^-^'-- 
"••.^'  calle,!  either  in  acute  or  c  Z  " ' '  "^■'''^'•^'  "•^"-'"  I  was 
-ttled  in  town  about  eig     e   .  :."?;  fr  "'^"'^  '  ''^'^ 

^^■-  ;vell  on  in  years,  .d.out  o  ab^^  ,^;^V  "  ?'"'  ""'''' 
•■v'-l.  ;o  begin  practice  in  Londo,;  '''''''  "  ''''  =^^^'''  ^^ 

^'•-i-«  <>"  n,edic.a  S^ts  ^  co;;/""-'"'."'  -"'■-P"i-'- 
^^■•■■•"  '-y  very  able  men  (  o ''"''!' ''^"•^'' ^'='^^"^^-' ^'^^^ 
'""^  '■<">!,  /^()^forn,s.me..!:2  ,Vr^"'^^  f''^""  "«  ^f'"<m 
^i«'n   on    books  of   tins  X  r^'  '"'"  ' '^^■^'^'J''"- ^''iti- 

"''''''^•--'ii--ad,a:d;.,r2E->,T-^V'r'''''^' 

t'!  ^^•'•'to  a  treatise,  on  some  minenl  w  , '  f  r""^^'  ^''""  ^^''^ 
of  n  particular  spa.  Sn.o  t  ,?  '  ""^'"^  ^''"  ^-'''^"^^ 
v^'-^'tliuns  an.l  dis  u.poin     'e' /   ,  "'  '""  '''^^  ^''^  trials, 

"'^'  P-fcssion  in  i\^.  i^^ ^t^^    ''''''  '^''  ^^"'liti-'  of 
""^M.cce,sful  attempt  to  introduce  hini- 


|v 


■■  : 


12 

self  ill   1(1  K a  say  on  the  External  Use  of  Cohl  HW/f?",  etc.     Dr. 

Jj II  with  iiis  "hotch-potch  of  criulitioii  ami  cxtnivagaiico," 

ami  the  pedantic  ihjctor  in  Perc(jrine  I'tckle,  in  wlioni  he 
satirized  (he  learned  Dr.  Akenside,  were  well-known  types; 
while  in  Dr.  Fathom  the  "ivystery  '  Oi  the  sons  of  I'aean,  as 
ho  terms  thorn,  is  mercilessly  exposed,  Amonj,'  the  "means 
nsed  to  force  a  trade"*  Smollett  mentions  "the  insertion  of 
cures  hy  way  of  news  in  the  daily  papers,"  the  erection  of  u 
"hospital,  lock  or  inlirmary,  l)y  the  voluntary  snl)Scrij)tion  of 
his  friends;  a  scheme  whicli  had  succeeded  to  a  miracle  with 
many  of  the  profession,  who  had  raised  themselves  into  notiee 
on  the  carcasses  of  thi  poor."  To  understand  Dover's  rela- 
tions with  the  apothecaries  (to  which  subsequent  reference 
will  be  made)  the  reader  must  know  that  they  were  the 
gener;il  practitioners  of  that  day,  and  dispensed  their  own 
medicines,  but  in  serious  cases  always  called  in  a  physician  or 
a  surgeon.  Smollett's  a'  'ouni  of  the  practice  "parcelled  ut 
into  small  enclosures,  occupied  by  different  groups  of  per- 
sonages," who  tossed  the  ball  (the  patient)  from  one  to 
another,  would  almost  lit  modern  usage,  in  which  a  jnitient  is 
sometimes  tossed  in  a  circle  from  si)ecialist  to  specialist,  until 
ho  returns  with  an  inventory  of  his  local  woes  to  the  consult- 
ant from  whom  he  started.  In  Smollett's  days  the  patient 
had  to  be  content  witb  three,  except  in  the  cases  requiring  a 
midwife.  "The  apothecary  being  summoned,  finds  her  lady- 
siiip  in  sue',  a  delicate  situati'  i  that  he  (.b.'clines  prescribing, 
and  advises  ..^r  to  scud  for  a  physician  without  delay.  Tiie 
nomination  of  course  falls  to  him,  and  the  doctor  being  called, 
declares  the  necessity  of  immediate  venesection,  which  is 
accordingly  pv;iioriued  by  the  surgeon  of  the  issociation." 

While  meriting  the  general  criticism  of  Latham,  the  wo'-k 
with  which  Dover  trusted  to  reach  Dvactice  had  many  import- 
ant (jualilications  for  succss.      .1  appealed  directly  to  the 


•This  seems  to  have  bee 


..t(i 


Engliah  Malady,  in  an  autob.    ■raphutil  note. 


irase  ;  Cheyne  uses  it  in  his 


le  uses  it  in  his 


13 
ins  Ihat  11,0  ,li«,,,..  i„  i,|     ,   „    ;  ,  '       """■'•,  '•'"  '"  "■'.■»rl- 

i»„.n  f..m„i,  :!z  ^  "•:':'.::""  r """  ^"■■■ 

t.o  other  booksHlens^    TtiA  '  ""^  :/f' 7'f,.^'"^  """'^'^  -'f 

of  which  is  in  the  British  Museun      J,,     l  '  " '"''' 

r-',  ■'  to  be  a  sofond  edit  on.     This  is  th,.  pn..ii.  of 

Lica^ry  of  the  Uoyul  Medioui  a      ("  h t,  ^U?  ,3  '"  /^" 

t.eH.,:.it^,,brar,^,,,,,^.,.,,^^,^,^^^^^^^ 

p.,^;.     .     different.      Korty-nine  years   of    practice   •ire         1 

Sryr  ^*^^'-'^^^^^-^-^that..;hrx:;;  ^ 

eftetts  of  n  ,         y  ^re  more  particularlv  on.idered."     After 
the  author's   name,  Thomas   Dovar,   M  Jj     .,,/,       ,       , 
r.ithr.nar,<sonthew,io.e..al.;,;'|pi;v;l'-^^^^ 
s  a  su  a  translation  of  a  treatise  on  niercurv'"by  the  l^Z 
Be  loste.'     It  v.as  printed  fo.  ,he  .elict  of  th'e  late  II  Bi   d  e ' 
i.  K.  .S.     1  he  second  and  third  editions  I  have  not  seen  ■  th 
was  probably  one  of     hem.     The  fourth  and  fifth  edtio 
also  appeared   m   i:;3;j;    the  sixth  in   174^);   the  sevent      n 
17G^,  and  the  eighth,  the  last  so  far  as  I  know  in  k" 

i  he  Ancient  Physiria^^s  1,.,,^,  in  the  langua^^e  of  one  of 
Dover  s  correspondents,  "made  a  great  noise  fn  London  Z 
was  the  subject  of  almost  everv  Coffee-liouse  " 


Iti 


14 


It  contains  a  tlescriptioii  in  jjlaiii  iangiiajjo  of  uhoiit  fi.rty- 
two  disorders,  iliustratutl  by  ca.-^utt.  tiit'  majority  of  wiiii  li  an- 
made  to  attcist  in  some  way  to  tiie  author's  xkill.  Tiic  later 
editions  aijoiind  in  letterfj  from  grateful  pationtd,  extolling 
luH  virtues.  'I'lu'  pictures  of  disease  are  scarcely  such  as 
might  have  been  expected  froin  .i  pupil  of  Sydenham.  'I'lir 
account  of  consumption  or  "phtisix,"  aH  he  .spells  it,  is  vcrv 
meagre  from  the  hand  of  a  conteni))orary,  possibly  a  frii-nd, 
of  the  author  of  the  J'h/hisioiUf/id.  There  are  evidences 
throughout  that  the  Iiook  was  written  "for  revenue  |»urpii>cs 
only,"  and  the  spirit  of  the  buccaneer  was  not  dead  in  the  old 
man,  as  no  occasion  is  nnssed  either  to  blow  his  own  trumpet, 
or  to  tilt  a  lance  at  his  colleagues.  '•  Let  me  but  come  to 
I'eople  as  early  in  this  Distemper  (dro))sy)  as  they  generally 
apply  for  relief  from  other  Physicians,  ami  it  shall  be  cured," 
etc. 

On  page  IS,  in  the  section  on  gcuil  is  given  the  formula  of 
his  famous  powder.  "  Take  Opium  one  ounce,  Salt-l'etre  and 
Tartar  vitri(jlated  each  four  ounces,  Ipdcacuana  one  oimee. 
i'ut  the  Salt,-l\'tre  and  Tartar  into  a  red  hot  mortar,  stirring 
them  with  a  spoon  until  tiiey  have  done  ilaming.  Then 
powder  them  very  tine;  after  that  slice  in  your  opium,  griud 
them  to  a  powder,  and  then  nu\  the  other  jjowders  with  these. 
Dose  from  forty  to  sixty  or  seventy  grains  in  a  glass  of  white 
wine  Posset  going  to  bed;  covering  up  warm  and  drinking  a 
cpuirt  or  tliree  pints  of  the  Posset — i)rink  while  sweating."' 
The  same  formula  is  repeated  in  all  the  editions.  lie  mvs 
that  some  apothecaries  have  tlesired  their  patients  to  make 
their  wills  ami  settle  their  affairs  before  they  venture  upon  so 
large  a  dose  as  froui  forty  to  seventy  grains.  ''As  monstrous 
as  they  may  represent  this,  I  can  produce  uiuleniable  proofs 
where  a  j)atient  of  mine  has  taken  no  less  a  (juantity  than  an 
hundred  grains,  and  yet  has  ap])eared  abroad  the  next  day." 

In  the  treatment  of  fevers  he  follows  the  practice  of  the 
"good  Dr.  Sydenham,"  for  whose  menau'v  he  i)rofesses  "the 
greatest  veneration."     "In   this    Distemper   as   in   all    other 


('  (if  aliolll  fdl'ty- 
rity  of  whi(  h  an- 
^^kill.  'J"lu'  Inter 
atientd,  extolling 
sciireuly  such  a.s 
Sydi'Uiiaiu.     Till' 

Hpells  it,  is  Very 
ujHsibly  u  frifinl, 
re  are  eviik'iuicfj 
revuiiiie  purjio.M'.s 
t  deatl  in  the  old 
Ills  own  trumpet, 
1110  but  come  to 
iH  they  general] V 

shall  he  cured." 

1  the  I'orniula  of 

;e,  Salt-I'etri'  and 

nana  one  ounce. 

mortar,  stirrin<r 

lliiming.     'I'heii 

uir  opium,  grind 

wders  with  tiiese. 

I  a  glass  of  white 

1  and  drinking  a 

ivhile  sweating."' 

Hi  ions,      lie  S'lv.s 

patients  to  make 

venture  upon  so 

"As  monstrous 

uleniablo  proofs 

i|Uiintity  than  an 

the  next  day." 

practice  of  the 

.'  jirofusses  "  the 

as    in    ail    other 


lo 

I'Vvers,  I  pr.scrihe  the  c,h,|  l.-.g;,,,,,,.  which  mii-t  h,.  r.,ll        , 
.Mc.asc     ankindp,vfer.//M.,,eath;,.;aL       A.^:' 
'■"»     Illness  to  a  long  and  l- dious  one;  a  good  t     t  1  n        ' 
"'Hi  shaltere,!  constitution,  h.vin.  asi.le  Mli^rer  '  >     ;  ,  ' 

-ng  and  poisonous   Po.ders."-    in  anoth'::"  .''':; 

rwl'T'-'''  ''"''''^^"^^"^  '''''--'-'-    H^^^ 


■■sinallpox.     in  thi 


ounces  of  blood  and  liad 


''^ginning  he  lost  tweni 


WHS  blind,  and  then  took  to 
my  room,  my  windows  were  c( 


It  vomit.     II,.  went  abroad 


wet 


•0  ordered  to  be  laid  no  hi.rlior  tl 


'"■''•     "I  had  no  lire  all 

)nstantly  ojien,  my  bed-dotl 


y-two 
until  he 
owed  in 


me  take  twelve  buttles  of  small  1 


'i"i  my  waist.     Jle  made 


vitriol  every  twenty-four  hours."  Tl..  . ,  „-,  ,^.„ 
V  referred  to  fre.,uently,  and  he  meiitVons' A 


^V'est   I 


"dies,  and  Hungary,  in  connect 


'eor  acidulated  with  spirit  of 

ieexj)eriences  of  his  travels 

siii,  the  East  and 


in  i)racticc.     There  i 


ion  with  special  luiints 


sailors  of  the  Duke  and  Duck 


^  an  account  of  the  plague  am 


two  cities  of  ( 


The  Ancient  I'h 


'iuiia(|uil,  under  tli 


•''■S  "when  I  took  bv 


I'Ks  in  the  .South  Se 


ong  the 


slorin  the 


ysician's  chief  legacy  to  hi 


lis. 


quicksilver,  which  was  Jiis  specific  i.rahnost 


th 


e   use  of  wlii(di   i 


letters  from  jiatients.     II 


s   vaunted  in  a  most  forcibl 


s  country  was 
every  disease,  and 


e  ordered  an  ounce 


a.juarter  of  crude  mercurv  dailv   1 


Jiatii'iit   from  all 


manner  iu 

or  an  ounce  and 

iifving  tliat  it  freed  the 


and  in 


•ormicular  diseases,  opened  all  obstructions, 


who  hat 


itUea])ure])alsamof  theblood.     A( 


lived  by  the  doctor's  d 


of  Snails  and  such  stutl',"  took  for  1 


irection  "on  As 


aptain  Ilarrv  Coit, 


iiiiilk,  Svr 


hreatli 

twenty  ])ound 
derii 


an  ounce  a  day,  and  took  altoo-eth 


s  cough  and  shoi 


■up 


tness  of 


r  an  hundred  and 


s   weight,     n.nvr  says  that  he  was   called 


ion,  T/ie  Quicksilver  D 


'OilvV. 


'J'hi 


in 


m  active  jiainphlet  war,  and  for  trt-ent 


merits  of  crude  me 


•cury  were  mucii  disuissed 


Legacy"  stirred  up 
y  years  or  more  the 


16 

If  Dover's  object  in  writing  the  work  was  to  iraia  jniblicity 
he  could  not  have  taken  a  better  way  than  in  his  sharp  com- 
ments on    the  ))hysicians   and   apotliecaries.     The   hitter  he 
assaults  in  terms  wliich  must  have  tickled  the  frequenters  of 
the  coffee-houses,  among  whom  we  are  told  tlie  book  made 
such  a  noise.     "I  never  affronted  any  Apothecary,  unless  in 
ordering  too   little  Physic;  and  curing   a  patient   too  soon 
IS,   ni  their  Way   of   ^I'hinking,  an    unpardonable  Crime.     I 
must    confess,    I   never   could    bring   an   Apothecary's    15111 
to  three  pounds  in  a  fever;  whereas  I  have  known  some  of 
their  bills  111  this  disease  amount  to  forty,  fifty,  and   sixty 
Pounds.  ^  If  they  can't  cure  with  less  charges,  I  can't  forbear 
saying,  That  I  have  t!ie  same  opinion  of  their  Integrity  as  [ 
have  of  their  Understanding."     The  doctrine  of  the  apollie- 
cary  was  that,  "Tis  your  WrituHj-FJnjsician  only  lolw  has  a 
litle  to  n   Fee."     Dover  takes  strong  and  most  reasonable 
ground  against  the  constant  varviuir  of  prescriptions  wlim 
there  is  no  occasion  for  it.     The  hostility  of  the  apothecaries 
to  him,  according  to  his  own  account,  arose  from  his  bein- 
"always  inviolably  attached  to  the  Interest  and  Welfare  of  my 
Patient  and  entirely  regardless  of  these  Gentlemen's  um^ar- 
rantable  Gains."     These  attacks  did  not  pass  unnoticed,  and 
in  1733  II.  Bradley,  Surgeon,  criticises  the  Ancient   Physi- 
cian's Legacy,  and  makes  some  "animadversions  on  his  <('ur 
rillous  Treatment  of  the  Professors  of  Physic  in  general;  uith 
a  word  or  two  on  the  uselessness  of  his  Legacy  to  all  Private 
Families." 

Daniel  Turner,  -of  the  College  of  Physicians,"  who  in  (he 
same  year,  "impartially  surveys  the  Ancient  Physician's 
Legacy,"  refers  to  the  Guaiaquil  incident  in  the  followi.io- 
terms:  "I  think  the  Doctor  had  much  better  have  left  out 
his  Bravado  of  having  taken  two  cities  by  storm,  unless  he 
thinks  It  an  honour  to  a  Physician  to  kill  and  slay,  and  after 
to  plunder  the  Innocent,  those  who  never  wronged  him,  and 
to  carry  off  the  spoil;  a  good  i)relude,  this,  to  the  blood  'shed 
after  among   his   own   men."     (Dover   had   had  them   bled 


i 


to  gain  publicity, 
111  his  sharp  com- 
3.  The  latter  he 
;he  frequenter.s  of 
:1  the  book  made 
hecary,  unless  in 
patient  too  soon, 
enable  Crime.  I 
.pothecary's  liilj 
!  known  some  of 

fifty,  and  sixty 
s,  I  can't  forbear 
eir  Integrity  as  I 
le  of  the  apotlie- 
i  only  tvho  has  a 
most  reasonable 
escriptions  wlien 
the  apothecaries 

from  his  beiii'r 
d  Welfare  of  my 
tlemen's  nnwar- 
5  unnoticed,  and 
Ancient  Physi- 
ions  on  his  scur- 
iu  general;  with 
cy  to  all  Private 

us,"  who  in  (he 
snt  Physician's 
1  the  following 
■r  have  left  out 
torm,  unless  lie 
slay,  and  after 
Juged  him,  ami 
the  blood  slied 
bad  them   bled 


17 

copiouslv  for  the  platrnn  ^     t 

quicksilver  did  not  a  mtle  to  h7"';""'  '''''  ^''-  ^^— ^'^ 
tragedian,  Earton  Boot  ovh' r;  Z'  ?'''■''  ''''  '^'^'^^''^ted 
3d  and  8th,  within  two  on  ces  o     ,  T''  ''''''''''  ^'^J 

Like  his  master,  Dover'^,^  L  i      /'"^"^^''  "^  ""^'•^•"•3'- 
lege  of  Physician;  w.^.;S  t  "'^'^  ^'^^  '^'^^'^^  ^o'- 

ti-  license.     Sydenham  irfM^r";;;!'"'  'i-^'i,ieation  of 

guished  English  cluneal  phvsioVnw'.  ""  "'"''   '''^fi"" 

regarded  as  innovators.       "":;:^/i^  ' '^'^  -"tury,  .,,« 

College,  who,  as  Svdenhani  reni  r  ■  ,  -  J  ''  ^"-"''^'  '^  ^'^« 
to  reduce  practic^  to  gr  at«  e  In.  °  '  T  ''  ^"^  =^"^'"l'ts 
coolness  and  moderatio.rof  u  e  t  ""  .^'"'"'"^-  '^  '^<^ 
"Ancient  Physician,"  whoin    1^  ' Tv"°'^""'^'^^'^  ^^^^he 

tlemen  of  the  faculty,  and^rt  n  1  f ""  f^'"'^-^  "'^S- 
every  Graduate  for  a  Physic  :;;"'"  ^''T'  "^'"^  ^'  ''^^^^ 
tlemen  forOracles."  II^^Z  r  "^  I'^-^Jmliced  (ien- 
aha,  or  as  he  terms  it  on  the  t  Ue  ^^'"  T''  '"''''''^"^'^^-Mor- 
of  the  College  of  Physic    n  T  ,  ^  ^^    %  'J  ^^'''  "'"''''  conversation 

dix,  togethj;  .iti:T^^^£:^'^'^^-)j>y-^^^^ 

tl^e  whole  purport  of  th^  "  C  n-ersatioi^ '' ^-^r"^  '""'''^  ^'^^ 
Ignorance  and  to  deceive  their  mis  n  I  .•'  "  '"'''''^^  '^''^^^ 
ins  desire  is  "  more  to  do  u  i  "  T  Ar  f  ^'""''  '^"'  ''^  '^^ers 
and  provoke  a  Set  of  ct^  ^  wh.^ t  ""'  /''"^  '^  '''^^'^ 
g'onnd,  lest  their  Practices  sho   1  '''"'  '''''^'  ""'l"' 

;-e."   He  again  refers  loU.:^^!^^^''''.^  '''  ^'"^'"- 
the  physicians  in  the  following^;:   '^r^™--^h 
r;nerally  speaking,  have  it  in  their  Tower  m      ^^l^«^'^»-'^«''i^^«, 
Plivsician,  which  is  the  wron-^es    ^     '^^^    to  recommend  the 
take:  The  Physician,  to  grTf^it^Y     ■'''"'* ^'^'^  ^^^^ 
self  obliged  to-order  [^  f^,;^  '  „    ^  tj'f  ^^'T'  thinks  bin. 
really  wants,  by  which  me.      V  T       "'"  ^''""  ^'^^  ^'^tient 
and  too  of  ten  li  lA^^^^^^f''}  T'  '"  ^'^^titution, 
cary's  Bill  in  a  Fev  Z-  "      ,ld  "  '  ''  ^'''''''^'  '"^  ^^l'^^'^^^ 

more  Pounds:^    C  'l         '/""°""\^"  '"'^-'y  "'•  i'^^  ft  v.  or 
several  of  those  Apo  Le  a        1  n^'a!^'  wf  ''''''''''  ^^^^ 

----.sicia;i,but.v;:t'z;;dr^;rr^:::;; 


(    ii 


18 

Shilling  ii  Day  into  their  Pockets:  What  must  the  Conscience 
of  such  Physicians  be,  tluit  would  forfeit  their  Eeputation  and 
every  thing  that  is  dear  to  them,  by  cheating  for  others  ?  I 
would  venture  to  say,  Neither  Sydenham's  nor  Eadcliff's  Bills 
did  ever  amount  to  Forty  Shillings  in  a  Fever,  and  yet  they 
recover'd  their  Patients  without  the  Kule,  at  present  pre- 
scribed, of  Vomiting,  Bleeding,  and  multiplying  Blisters  in 
all  Cases  whatsoever;  so  since  this  is  to  be  their  Rule  of  Prac- 
tice, they  are  very  indifferent  in  their  Enquiries  what  the 
Patient's  Disease  is." 

Dover  continued  to  practice  in  London,  and  in  the  seventh 
edition  of  the  A.  P.  L.  there  is  a  letter  to  him  from  Catherine 
Hood,  dated  November  6,  1738,  in  which  she  speaks  of  havincr 
consulted  him  in  1737.  ° 

In  1742  appeared  the  sixth  edition  of  the  Legacy,  which 
must  have  been  issued  by  the  author,  as  he  speaks  on  the  title- 
page  of  fifty-eight  years  of  practice.  He  is  stated  by  Munk 
to  have  died  in  1741  or  1743,  probably  the  latter,  but  his  name 
does  not  appear  in  the  register  of  deaths  in  the  Gentleman  » 
Magazine  in  either  of  thoKe  years. 

Doubtless  the  old  buccaneer,  described  "as  a  man  of  rouoh 
temper,  who  could  not  easily  a-  '  e  with  those  about  him,"  ^uis 
a  striking  figure  as  he  passed  along  the  Strand  to  the  Jerusa- 
lem Coffee  House,  Avhere  he  saw  his  i)atients.  A  good  fighter, 
a  good  liater,  as  alas!  so  many  physicians  have  been,  his  weak- 
nesses and  evil  behavior  we  may  forget,  but  Captain  Thomas 
Dover,  who  on  the  2nd  of  February,  1710,  fouiid  "Robinson 
Crusoe,"  the  world  should  not  forget;  and  we  also  of  his 
craft  have  cause  daily  to  remember  with  gratitude  the  student 
and  friend  of  the  great  Sydenham,  who  had  the  wit,  in  devising 
a  powder,  to  remember  his  master's  m]\mci\o\\:  Sine  papa- 
veribus,  si?ie  opiatis  et  medicament i,«,  ex  iis  confcdix,  manca  et 
clauda,  esset  medicina. 


.1 


the  Couscience 
Reputation  and 
for  otliers  y  I 
Eadeliff's  Bills 
,  and  yet  tliey 
\,t  present  pre- 
ng  Blisters  in 
•  llule  of  Prac- 
iries  what  the 

in  the  seventh 
rom  Catherine 
eaks  of  having: 

Legacy,  which 
ks  on  the  title- 
,ted  by  ]\Iunk 
bnt  his  name 
16  Gentlema7is 


man  of  rough 
iQut  liim,"  was 
to  the  Jerusa- 
.  good  fighter, 
eeu,  liis  weak- 
ptain  Thomas 
id  "  Robinson 
e  also  of  liis 
le  the  student 
it,  in  devising 
1 :  Sine  pupa- 
'ctis,  manca  d 


lili^  i. 


h\         :H 


«S»BB«08^ 


CLk\/< 


January,  is;).;,  ' 


^^N  ALABAMA  STUDENT 


n\- 


WILLIAM  OSLER 


H  A  I.TIM  OH  K 

■r"R  fRrKnENn'Ai.D  company 

I  son 


I!'     I 


i     I 


~ym 


! 


"WaB'to:*^,, 


11 
fi 

b 
ai 


'"°"'"'""'^^-'-— ~.Xo...,., 


"ary.  IS!*.] 


AN  ALABAMA  STUDE.V 


T. 


t'hief  iinionc-  the  lvii-,i  ^     ■ 

iin  me  is  not  wortliv  of  i 
tecepfaiiee,  and  wiijch 


th 
its 
is- 


i-'i'  01-  niothei- 
Yet  tJit 


11  le. 
is  r 


lara- 


:(?r  more 


■or  rather,  perhaps,  as  it  wu 
li'i'=  compelled  men  to  follow 
near  and  the  dear  on 


-IS  th 


«'•  son  or  dauo-ht 
jin^th,,tniaaei,os;ihi; 
"lity  as  it 


•esponsible  for  Christ] 


iileals,  even  at  th 


"»e  which  in  all 


ao-es 


tinieor  another,  the  call 


^s  at  home.    In  varied 


ot  a  stndeut;  to  the 


i(?  sacrifice  of  the 
tones,  to  all,  at 


scorn  delio-hts  and  ] 


S 


innvasi.     :\r, 


third 


to    1 


i^c  the  labor 


one 

and  follow 

ous  davs 


as  the  old  Greek  h 


^'"3;  are  the  wand-hearers,  f^ 


■^^"ounce  all  in  the  life  of 


M 


any  are  called,  but  fe 


as  It,  or.  in  tlr 


;e  \\ 


are  th 


e  mystics 


tied,  but  th 
Th 


e  same  spirit 


are  chosen.     'J'] 


o''ds»-h,eh„.eknowbette 


iiiimated  the  "  fi 


le  gifts  were  d 


iversi- 


.  -f'V-   the   patient   so„l   of   P."        """"  ''''''  ''  ^^' 
™g|ity  intellect  of  John  Plunter.'  ^'""'''  '"^"^^  the 


We  honor  th 


the  story  of  their  1 


could  not  have  be 


lose  who  i\ 
i^'es;  an 


pond  to  the  call;  we  1 


d  ^vhile  feel 


ill''- 


recognize  in  the  power  of 


-".;vitlithem.faithfuI°„;tode 


ove  to  tell 
Perhajis,  that  we 


ath,  yet  we 


o"'"i=   in   Liie   nowei-  nf  lu  ■  --' "v.iLii,  vet  we 


' chose 
men.     They  see  of  tir 


are  oft 


en  not  h 


H'py  men.  often  not  th: 


my 


lied 


and,  in  the  bi 


trei 


'C  travail  of  th 


better  than  their  fatli 


•lie 


■ss  of  the  thougl 


leir  souls  and 


and  die 


ers,  ai 


'it  that  thev 


■sties  ■' 

iccessful 

i'"e  not  satis- 


•^  ready,  with  Elijah,  to 'lie  dow 


are  not 


u 


4 

To-iiiglit  T  wisli  to  toll  you  the  story  of  a  man  of  whom  yon 
have  never  heiinl,  whose  name  is  not  written  on  the  scroll  of 
fame,  but  of  one  who  heard  the  call  and  forsook  all  and  fol- 
lowed  his  ideal. 

AVhen  looking  over  the  literature  of  malarial  fevers  in  the 
South,  chance  threw  in  my  way  Fenner's  SiMthern  Mndital 
Reports,  ^'ols.  I  and  II,  which  were  issued  in  1849-50  anil 
1850-51.  Among  many  articles  of  interest  I  was  particularly 
impressed  with  two  by  Or.  John  Y.  I^assett,  of  Ilutitsville, 
Ala.,  in  whom  I  seemed  to  recognize  a  "liken.-ss  to  the  wise 
below,"  u  "kindred  with  the  great  of  old."  I  wrote  to 
Ilunt.sville  to  ascertain  what  had  become  of  Dr.  Bassett,  and 
my  correspondent  referreil  me  to  his  tlaughter,  from  whom 
I  received  a  packet  of  letters  written  from  Paris  in  183(;. 
I  have  her  permission  to  make  the  extracts  which  are  here 
given. 

By  temperament  or  conviction  there  are  a  few  men  in  every 
community  who  cannot  bow  to  the  Baals  of  the  society  about 
them,  and  who  stand  aloof,  in  thought  at  least,  from  the  com- 
mon herd.     Such  men  in  small  circles  tread  a  steep  and  thorny 
road,  and  of  such  in  all  ages  has  the  race  delighted  to  nuike 
its  martyrs.    The  letters  indicate  in  Dr.  Bassett  a  restless,  non- 
conforming si)irit,  which  turned  aside  from  the  hollowness  and 
deceit  of  much  of  the  life  about  him.     As  a  student  he  had 
doubtless  felt  a  glow  of  enthusiasm  at  the  rapid  development 
of  tiie  science  of  medicine,  and  amid  the  worries  and  vexations 
of  a  country  practice  his  heart  burned  with  the  hope  of  some 
time  visiting  the  great  centres  of  learning.  As  the  years  passed, 
the  impulse  grew  more  and  more  urgent  to  go  forth  and  see 
the  great  minds  which  had  controlled  his  hours  of  study.   All 
students  Hocked  to  Paris  in  the  fourth  decade.     Nowhere  else 
was  the  pool  so  deeply  stirred,  and  Laennec,  Broussais,  Louis, 
Andral,  Velpeau,  and  others  dominated  the  thoughts  of  the 
])rofession.    One  can  imagine  how  carefully  the  plan  was  laid, 
antl  how  for  years  the  little  surplus  earnings  were  hoarded  for 
the   purpose.      But   the  trial   which  demanded  the   greatest 


coura-o  was  the  k-uvin-  of  wif,        ,    ■  •,  , 

r'r' '"  ^''^  '^'^--^  -1-1.  i^ii  ;i  t  ";■' ""  ^'"'••^  "- 

l«ur.l.n.,t  nnl,v,l  without  biUc.n,.TT  '  '*''""'•-'  ^"^ 

for  a.>  apparent  crueltv  in   i.,vi,  .'h       T    S'''^'  f-VMU-ndy 

profession  ;  and  ti.e  nd.hho  ^      f,     ""    ''■.  ''"'■  '^''^-  "^'  l"' 

poor  wife,  whose  desertion  t'  ev  ''^■"  ''  ^'"■^'■^■''  <■'"•  "''^ 

of  H.e  letters  ho  savs;<!s-,r'^;f''''''^'''^'''"'^-     '"""e 

-ii..ve.aad,ou;,,;,ht;i::^r,.7'^''^^"''^  ^^■^"' 

construction  on  such  remarks-  tl,      '  "  """^  charitable 

'"tok  wilipos«ih,v,,,  ,  havT;,^ tr';"^""''''^^^''^"  ^  ^-'"e 
of  ti'iH«nrtare,nadJcare]essIv  T^'  .^'^""-^'"'^^  ■'emarks 
sometanes  fn.n,  wantonness,  as  luv,,r;f  "^^°'^  ^^■^"•'"^5 
'""1  pierce  them  with  pins'  son,  il   ^  "  '""»^'°f  "'^^ 

«lHK,t  inoffensive  creature"  .'h'r'  "'"  '^l'"''^' ''^  '""'^'■'•« 
for  sj.ife,  as  we  kill  lleas  •"  son'ie/r'  ."''  '"""'''  '''0'»^'<i>Hes 
losophers  torture  dogs  •  Ii'.tt  '  f  "  ^^'1'^"'"^'"^  -^  I'ln"- 
«'<■•"  .suints.  and  asl  ,  ;  ,  "  !'™"^  ^"^'^^'1"^^^^^^  1-ims 
anoUier  he  savs,  <^\rv  "^^^^^^^^^^^  "^'"  ""^  ""^t''"'"-"  And  in 
man's  repent,u,ce.  kno^uZ'"'  ""  "  ""'"^  ^'^  =^  ^^^ 
for  and  fro.n  me.  and  wi  ,:;:';;'' r""'  ''-■^'  ''-''-  "-eh 
you  may  do  it  pleasanth  -n^'"  -"S;-''and  I  hope 

to  know,  you  have  a  h.i^la  ' ,  ^  ""•^'.^'''^t.tication  to  you 
The  lelters  begin  f^mP,"  ''^'^'''^''''^  .vour  conduct." 
l>ocen>ber,  ]S3o.  ^  e  1  ai  o <t  "'r '1  '"  ''''  ''"''  ^^'^^''^  ^f 
'»•■  .^unes  II  grille  \^^iv:V;^^w''^°''  ^''  '^W^l'-l  ^o 
of  the  Washingto  L  .1  Cof  T  f'^f-sor  of  Anatomy 
found  an.ong  The  pa  e  s       , r     T  f?"  '  '"■"''^=^*^^'  ^^'J"^'''  i^ 

o^;;.-i-iLion!r:;.r2i::;t:^:,;:;;?'-'-^ 

eating  letter  an      c^nt  !  T  f"'  '''^'  ^"'^  '"  ^^'^  '"'"- 

tl-  '^-..i.h  ('llu:  :ruS'^:^;;f  ^^  7^^-  ^^^^ey  reached 
given  of  the  fine  way  i„  w  eh  tt  ^^'''^'''S^^^scnption  is 
Pac'ket-ships.     He  eLr  a     hi    .   f  ^^''^f '!-^^^-='  ^^^'^^  on  these 

go  well,  though  si  iX^ :  :  :'^^^^"-  ^'^^^^^^n  -uw 

-l-.egshennall4.rt^^u2r;^----^ 


6 

on  oarth  iiiul  gooi)  will  towards  men."  He  express  .s  great 
anxiety  about  the  training  of  iiis  two  children,  and  bids  her 
not  to  spare  the  rod  if  necessary,  saying,  "us  the  twig  is  bent 
the  tree  inclines." 

The  first  long  letter,  descriptive  of  Manchester,  York,  and 
Ediubnrgh,  is  illustrated  by  very  neat  little  sketches.  He 
was  very  much  impressed  with  Vorl;,  and  says  that  "  if  ever 
I  was  to  l)e  born  again  1  would  like  it  to  be  at  York." 

In  Edinburgh  he  visited  everything,  from  the  fifteen-story 
hovels  to  the  one-story  palaces.  He  gives  a  description  of 
some  graves  at  Leith  covered  with  iron  grates  and  locked  to 
keep  the  surgeons  out,  and  over  which  a  watch  was  kept  the 
entire  night.  He  was  enchanted  with  Edinburgh  in  all 
matters  except  one.  He  says,  "0  .Scotland!  thou  land  o' 
cakes!  0  Edinburgh!  thou  city  of  learning,  thou  cluster 
of  palaces,  thou  city  with  suburbs  in  the  centre  and  precincts 
fit  for  *'be  residences  of  priiu-'s,  thou  modern  Athens!  whose 
candl'i  v-'vi'm  to  emulate  the  stars  in  height,  if  not  in  lustre!' ! 
Coit'^i  ',  ji!  act  invent  any  other  method  of  getting  your  coal 
cut  \.>t  ■  !iL  mine  save  on  the  backs  of  females ! ! ! !  It  is  a  fact 
that  tit  •;•■>  are  women  whom  tliey  call  bearers,  whose  business 
it  is  to  uarry  coal  out  of  the  pit." 

He  was  very  enthusiastic  about  the  museum  of  the  College 
of  Surgeons,  and  tlie  Infirmary,  where  he  witnessed  in  tlio 
presence  of  Mr.  Syme,  an  operation  by  '•  Mr.  Ferguson,  a  young 
surgeon." 

PVom  Edinburgh  he  proceeded  to  Glasgow,  then  to  Belfast 
and  Dublin,  and  then  on  to  London,  where  hespeut  two  weeks, 
aj)parently  of  great  misery,  as  the  weather  was  atrocious.  lie 
shook  the  mud  of  England  from  his  feet  at  Dover,  and 
departed,  hoping  never  to  be  soiled  with  it  again. 

He  took  a  through  passage  from  London  to  Paris  for  XI 
18s.,  and  he  gives  an  amusing  description  of  the  additional 
payments.  He  asked  the  master  of  the  hotel  to  give  him  some 
information  regarding  P'rench  traveling,  and  got,  he  says,  a 
regular  English  account,  Johnsonian  without  his  wit.  "  They 


;'guson,  a  young 


will  ohcuf  you  at  every  ston-  fi, 
i~3ouwit,,,,iH;:,    ^,;i^^];-      -'-you^ 

"'"tton  or  beef,  and  notlnn-      ,  !  '''  '  >'°"  ^^''"  S^t  no 

"'''l.ou,.h  I  paid  everytZ^i  ''";'■  "r""-  ''''•^•"  ^^  ««V8. 
of  ti.e  little  extra  cha^l  ?,  ,  ""'^r'  ';."'  ^'"^  >'^"  '^  ''«* 
e-espuicl."     IIegiv,.;aui(        :ri'i;;;y';'-'f'  ften 

charges  in  the  two  ikvs  and  n,,  ''■''"*^'-  '•'•^tra 

diligence.     One  of  Ui^  Z  7''  ''u''''  '''  •^l^" '  i"  ^''o 

-filing.     notoIdS:/":tT'"""^'''"^'''-' 

over  his  ladder.     "To  the  ,,„  .  ^        '' '^"'^  J^mp^''! 

for  seeing  that  nobody  cleZ    '''',"':';  ''  """  '''  ^'^  ^o^els, 
"The  conunissioner  o^f    1     a-n   "'  1^"   l"n.self,  si.  ^billings.'' 

damned  ra.cals,  for  l^cLe    ,1'  f ;"::;,/  ^,rV""'^^^  «^  '"^ 
and  sixpence."  '^  ^  "  '""^  ''^■l"'g  lies,  1  shilling 

seau  ;  and  tlie  Pantheon   in  w  i      °  •"'^"""'^  ^"^  ^ous- 

tl-i'-  bodies,  fron.  v  ;  :  ut  T:  f'  1,"°"'^  '^"l-^'^^d 
its  classic  front  before  n  v  u  W  n  T  """  '"""'  '^^'^^ 
not  so  much  of  an  iniide U  '^  °"  '^  '^'"^  ^^-^^l  ^  '^m 

^He  attached  hi.:;S::^r  n-Uc^fvP"-"^''"^^-'' 
Charite.    On  his  (Ir.st  day  he  ..v.  b!  .  .         ''^''^"  =^^  ^.a 

than  half  he  said  but  1  cm  nd^f  Vl  "°^  ""^erstand  more 
there  was  a  gentlJm:!  t  1S:^^^  TT"":-  . '''  "^^^ 
there  for  three  years.    Americ  u  s    '  !  '  '''^''  ^'''"^  ''"''' 

four  or  f,ye  from  \ew  Yo  1  f  /  ^^  '"'''^^^^  "'^■'•^'  ^^ere 
from  Boston  a^^P  i.',:  'h  7  ^7^"'"^  ^'"^  — » 
nume.sbutitispleasa  toU  n^^^  '^T  "°^  '"^"^i«"  «>eir 
ut  La  Pitie  with    Wd  tch        V      "^^^  '"""'^^  "'''''' 

Stille.  He  luJn  ci  c  •  :/^  "'''  '"""''  ^'''^''"^  '"^^ 
six  francs  an  eS    and  .°"'''  '"'^^^^^^  ^^■^'''^  ^I'-'l- 

forty  sous.  ^        ^^  ^'"  '""""-^ ''  '^'''^'  «"  ^1-  'i^'st  day  for 

-iS-^™tr^ 

a  to  pay  but  toi  the  private  courses,  and  the  fee 


IMAGE  EVALUATION 
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Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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is  small  for  them.  The  facilities  for  the  study  of  midwifery 
are  astonishing ;  there  are  plenty  of  cases  always  ou  hand,  and 
this  I  deterni.aed  to  profit  by."  In  a  letter  of  ilurch  IGth  he 
mentions  his  daily  routine:  "I  get  up  in  the  morning  at  six 
o'clock  and  am  at  La  Charite  by  seven,  follow  Velpeau  until 
eight,  see  him  operate  and  lecture  until  half  after  nine,  break- 
fast at  ten  at  a  cafe.  At  eleven  I  am  at  a  school  of  practical 
anatomy,  where  I  dissect  until  two.  Then  I  attend  a  class  of 
practical  surgery  until  throe ;  then  hear  Broussais  and  Andral 
until  live;  then  dine.  At  seven  I  attend  ilelmagrande's  class 
of  midwifery,  which  lasts  until  nine ;  then  I  come  to  my  room 
and  read  or  write  until  eleven,  when  I  retire." 

He  was  much  impressed  by  the  opportunities  for  dissection. 
In  his  letter  of  the  third  of  July  he  says:    "There  is  a  dis- 
secting school  at  C'lamart  for  the  summer  on  a  most  extensive 
scale.  There  is  rooxn  and  material  for  200  or  upwards,  though 
there  is  but  few  there  at  present;  this  place  was  provided  for 
the  inscribed  students  of  the  school,  and  they  get  their  sub- 
jects for  a  mere  trifle.     There  is  not  the  least  prejuuice  exist- 
ing here  against  dissections ;  even  the  subjects  do  not  seem  to 
mind  it,  though  they  are  aware  of  their  fate,  for  more  than 
two-thirds  of  the  dead  are  carried  to  the  I'Ecole  Pratique  or 
Clamart.     I  have  private  instruction  in  the  use  of  the  stetho- 
scope for  heart  complaints  in  La  Pitie.     The  other  day  an  old 
woman  bade  me  adieu  as  we  passed  her  bed  without  calling,  and 
I  stopped  to  ask  if  she  was  going  out.     1'hen  she  said  she  was 
going  to  Clamart,  and  that  w  .1  might  meet  again." 

He  had  evidently  occupied  his  time  to  good  advantage,  as 
early  in  July  he  received  from  Velpeau  the  appointment  of 
exfinie  at  La  Charite.  He  says  in  his  letter  of  the  10th  of 
July :  "  I  have  ;>.  piece  of  news  to  communicate  that  1  know 
will  gratify  you ;  at  least  I  feel  very  much  gratified  myself. 
This  morning  1  received  the  appointment  of  externe  in  La 
Charite  under  Velpeau.  The  duties  of  an  externe  require 
him  to  be  ac  the  liospital  at  six  o'clock,  answer  to  his  name, 
follow  the  surgeon  round  a  certain  number  of  leds,  attend  to 


his  prescriptions,  a-^.l  to  dre^s  tlu-  ,    r 

-e  receive  nothing,  and  tl^^^^''^'     ^--  ''-  -.'vice 

yououghttobegrutitieduttln    V  °'  '''  ^'">'  "«fl'i"^S- 

I   huve  not  been    wasting    n    't  r"""'  ''  '''''  -'-ince  vo'u' 

starting  for  Switzerland  and  L  ',"  ""'  ''"  ^'"-'  ^^'^  of 
celebrations  on  the  -th  ^St^^aZ^'f'^  *«  "i^'^.s  the 
was  nude  me  I  did  what  I  h  vo  '  ''"'  ^^■''^"  ^'"«  «ff^^v 

another  sacrifice  for  n.y  pr  f  i^"  'T?  '"  "'-^-  ''^^^— ^^' 
and  take  the  servic.  I  have  1  '  ""'^  ^^'-''^''^i^ed  to  remain 
W  been  in  Europe ;  it  is  a  re  Ue^i;  Z'  ^'^^''^^^  ^^'-e  I 
He  was  very  much  impressed  ,1"  f'"'^'*^'""'^  ""solicited." 
the  French  physicians.  lie  ...v.  -  V"''''""^  industry  of 
the  medical  men  by  w'^om  t'.,V  '"      '""'^'  "^  -^onie  of 

blnsh  for  shame;  Jid  men    hn"  '""T'"'^''''  ''  ''^'^^'^  '"« 
white  locks  with  bovs  and   ,        '        '  ^'  ''''^"  "^'-^i'-S  their 
-nlor  of  youth.     S^^el',^  '!:""^  ^''^^^-  P™^--n  .^th 
that  is  idle,  for  if  he  ^^.^V.^     '' ^''^''  "'-^  "'  France 
stripped;  it  is  a  race, and    he     '.i  •  """""'  j^'  ^^'^"'^^   '"^  «"t- 
are  not  pressed  by  others      ZnTT ^' ^'' '^''''^  ^'>='t  they 
there  are  none  allowed  to  '     1  f^'"''  ^'  "  '''''•  ''"'^ 

I^onssais,  lecturing  and  h^'^S^t  "":"•  "'"^^^ 
after  having  elevated  liimself  to  h  '  ?  ""^"'"  ^''"'■^'-''f. 
bachelor  with  thousands  d,  ,f  ^  ^'T'^'' '  ^^'^^^'•-'^-  an  old 
h-on  for  ten  months  bV  ]);";'  '"''"^''f  ^"^^ '^-'yvi^it  and 
iJionths  he  from  choice  oiv  ,  '^''''''^ J^''  vacation  of  two 
Bollier  may  be  seen  daih^  ,'  Vo,..-';''' "^  ^Tf  "''•^"'^ '  ''"^^  ^'^^ 
bed-post  as  jolly  as  .f  1  e'T'f  ;.'';"''  '!'°'"  '-H-o.t  to 
f-ni  a  poor  boy  without  mo  e     tim     e"'  T''     '■^''^"■''"' 

^j;._^>aust,madehimsei;^:;"s:;;rs:rs::g:rt 
"The  pupils  of '30  Cs  :!rit:"T "'  ^'''•^■"^'•^^^•^ 

a  little  less  than  our  old  \ '  shi.  .  1      '' ''  "'  '^'■«"=^^' 

Broussaisisagenius,^!:       ''°tt:;:^"r^''"'^^•- 
-eth.ngwastobedone,orrath:r^rttJr^r:^r 


f 


jt  '4 


10 

tiling,  and  he  seized  the  science  of  niedicine  as  a  good  old 
jootur  would  a  bottle  of  lotion,  and  shook  it  n.tn/,  Hy 
l^f^^^rnauy,  all  Europe,  parts  of  Asia,  and  A  ne^Ja 
have  fel  the  agitation.  Jiut  younger  n,en  also  feel  the  n  ces- 
V  ,.  don.g  son.thing  and  they  are  now  endeavoW  g  ^ 
•luiet  the  comniotiuii  he  has  raised,  and  in  France  thev  Lve 
nujasurably  succeeded  When  the  giant  dies  I  doubt"  i 
i  -^^  ^f^^'^^^ov-lus  conquests,  like  Alexander's,  will  he 

uuled  and  then  fall  into  insignificance.  He  fights  well  while 
u  the  rn,g  against  awful  odds,  for  the  truth  is  against  htm 

,         '•  .,,    'f  -'  '''*'"  '^''^"^  to  «"ter  the  field,  and  I  have  no 
I  oubt  will  p  ace  a  splendid  monument  over  him,  to-      ven 
liim  from  being  forgotten."  P'e^enc 

"  r  am  glad  I  know  what  great  men  are.     I  am  c^iad  I  know 

o    what  they  are  made,  and  how  they  made  themsel^s  g    a 

Kuigh   this  knowledge  has   broken   the  last  of    my   ho ise- 

H>  -1  gods ;  yet  it  has  taken  away  the  flaming  swords  t  la  Xod 

H'ture    he  gates  of  this  Paradise,  where  may  still  L      IX 

ck  of  the  serpent  and  of  the  .levil  himself,  so  I  will  keep 

out  of  bad  company."  i^ 

Scattered  through  his  long,  often  closeh-crossed  letters 
there  are  here  and  there  some  choice  bits  which  indicate  he 
Huracterof  the  man.     For  months  he  did  not  he  •  Jd 

f.om  home;  then  letters  came  at  long  intervals.     1  4 

enty  had  been  re-i^ading  some  of  his  wife's  letters,  in  "^ 
o    which  she  had   been  reproaching  him  for  using  strom 
language.     He  says :  "  Isaphaena,  you  tell  me  to  break  m      ,f 

ion.  of  rehg.on ;  that  it  will  make  enemies,  etc.  Xow  listen 
to  ine  while  I  speak  the  truth,  for  on  this  subject  y  k lo w 
th^        always  do  speak  what  I  think  is  .rue.  I  ncvei'did  s." 

it'j  nl  'r'  '*  ''"'"'^  entirely,  for  nobodv  wou  d 

1  1  e„tand  me,  and  it  would  be  useless  to  waste  breath  when 

;"ow     can  put  it  to  a  better  use.     As  ,to  religion,  ther    il 

"ot  much  here  of  any  kind,  and  I  assure  you  I  have  not  ^aid 


u  ■■  .    ■ 

J^ere,  where  VoltaireJJo  ,^  '  ^  ^f  "°''  ^'"  ^  -P-t  to;  ...d 
mighty-minded  n.en  eU  id  f  r  ^^^'^'^ -'-fellatio,,  of 
Isaphuena-notsomuchuuh;  /'"^r  and  died,  1  fel- 
by  ciuTch-going  people.     W  ';;•'''"  "^''""'^^"■■'■«""decl 

f^omeut  doubted  the  sincor  v  of  ■''  ^  ^'''^  '''^ver  for  a 
l^«n'e  I  looked  into  the  e v  1  7  Tf'''  ^^•'^'"'«'  ^"tat 
--there  I  saw  ignorance  1::;::^'""  ^'"  ^''^"'' ^^^'-^^ 
they  were  the  nio.t  pron-i  ,e  .r      ,1  .T''  ''''  ^^''^"'o^t; 

seen.  Here  I  still  look  on  Jv  j  °''  'jf  T^  '''^'^''>'  ^^  ^ 
^^<ve  me  from  a  cou>Ur„  ,  Jltll  '"^  ^'"'^  '^  ^^''•""^''-^-  ^'W 
-^^  /^-r  know  you  will  ^1  ^'^^^-^^//--.^mv..., 
-and  return  nie  safe  to  a  count"  ih  r  "''  "^"^^  ^^"^^'"'^e 
n^ent  without  it.  I  an,  con  td  hi  h  '^"""  ""^  ''  ^-^•-- 
are  worse-ay,  nu.ch  u-orse-^Z  '  ''''^  °^  ^"''^^'Hty 

"Had  I  the  talents  of  M.  >  '"'  ''^'°'""  whatevu-."  ^ 
^«t  spend  it  as  they  did  or  fn^n"?"'^'"^'^  "'*^"  ^  «-o"ld 
effect  produced.  Thei  ^  .  J  "  '^  ^^'f^^'  -"'^^  they  see  the 
of  a  corrupt  priesthood-  ut  htif'^T^"  '''''''  ^'^^  evils 
tools  given  to  children     J   'L  ^"'"'^'^  '''''   'i^e  edged 

theii  rehned  and  perf  'tec      "       '"T'  ''  ""^  ^-'f^^^'  -'<1 
and  if  we  were  perfec    w    1   '  "^  '"°'"^'''^  '''^^  "«t  apply 

--Is  of  truth  \nt:^:::)l'  -^  "-^  then.     I  speaJ^lS 

■ne  evidently  was  of  Sf  r>  v 
subjection  of  the  wife!  li"!  ' '^•^'"°"  ''"''^'  ''^^'^'^^^^^  to  the 
b'^ve  spoken  cross  to  you  scolIdV"'  ^''''•'  "^"^^*  '^  ^ 
duty  it  was  at  least  n  rm-  viW  /r"'  ^^  ''  ''''  ""^  "'7 
pleasure  of  doing  it  ao  In^  .  >''  '"^?  \'^-^P^^t  to  have  the 
offends  to  cut  it^off,  et^  ,en  s  elv  i  '''\' ''  """  ''^^"'^^  '^^^ 
we  ought  to  have  the  li-  ert v  of  u  /  °"'  '^^""-'^'^1^  offends 
His  last  letter  is  fronp. ';'??;'  ^^"'^•" 

;-entS:;;::t::r,:-^^^^^ 

by  the  first  of  the  yoar    1  f  h  ,      I       T-  ''"''''  *°  ^'  back 
-snmed  practice  at  nu;>::,ne         "  ''"  '''''  ^^  ^-^-^'^ 


M    !  J 


■uw'.aim 


m 

The  two  papers  in  Fenner's  Southern  Medical  Reports  are 
the  only  ones  I  see  credited  to  him.  They  are  cluiriningly 
written  and  display  in  every  page  the  wise  physician ;  wise 
not  only  with  the  wisdom  of  the  schools,  but  with  that  deeper 
knowledge  of  the  even-balanced  soul  "  who  saw  life  steadily 
and  saw  it  whole." 

The  Report  in  Vol.  I  deals  with  tlie  to]50graphy,  climate, 
and  diseases  of  Madison  County.  Dr.  Fenner  states  that  it 
was  accompanied  by  a  beautiful  map  drawn  by  the  author, 
and  a  large  number  of  valuable  statistics. 

In  an  historical  sketch  of  the  settlement  he  thus  depicts 
the  early  border  life:  "'J'he  most  of  those  who  did  not  pro- 
cure homes  at  that  time,  belonged  to  a  class  who,  from  taste 
or  compulsion,  had  separated  themselves  from  the  whites,  to 
live  on  the  trail  of  the  Indians;  and  who,  like  tigers,  and 
Judases,  were  not  without  their  use  in  the  mysterious  economy 
of  nature.  They  suri)assed  the  natives  in  physical  force  and 
in  genius,  and  equalled  them  in  ferocity.  ^  They  had  the 
piratical  appetite  fi»r  gain  natural  to  the  English  race,  which 
they  had  culd\aled  among  the  whites,  and  they  readily 
acquired  the  Indian  taste  for  blood." 

"  Thus,  without  any  i)articular  standard  of  morals  of  their 
own,  and  having  fallen  out  with  that  which  restrained  tlieir 
Christian  brethren,  they  found  their  interest  in  adopting  the 
ancient  one  of  Moses  and  of  the  savages  among  whomthev 
resided— 'An  eye  for  an  eye,'  and  'blood  for  blood  '." 

"These  men,  like  the  fabulous  Behemoth  that  lay  in  the 
reedy  fens  of  the  early  world,  drinking  up  the  abundant 
waters  and  eating  down  the  luxuriant  forests,  to  make  way 
for  civilization,  have  left  little  more  than  a  vague  tradition  of 
their  existence  and  exploits,  the  latter  of  which  has  been  so 
embellished  that  the  former  already  begins  to  be  doubted." 

"yuch  a  race  leave  but  short  records  of  their  diseases. 
Where  bloodshed  is  always  epidemic  and  every  man  his  own 
surgeon,  the  few  that  recover  feel  grateful  to  none,  and  hang 
no 'votive  tablets' on  the  natural  columns  of  their  forests"; 


Kej^orts  are 
cliiinningly 

siciun ;  wise 
that  deeper 

life  steadily 

ihy,  climate, 
tates  that  it 
the  author, 

bhus  depicts 
:lid  not  pro- 
,  from  taste 
e  whites,  to 
tigers,  and 
us  economy 
.1  force  and 
ey  had  the 
race,  which 
ley  readily 

•als  of  their 
aiued  their 
-lopting  the 
whom  they 

lay  in  tlie 
i  abundant 

make  way 
;radition  of 
las  been  so 
oubted." 
r  diseases, 
an  liis  own 

and  hang 
3ir  forests ; 


W 

and  when  a  missInuM,.,. 

-,d  pu.ie  H  ;:::i:- -^^^^^^^ 

a«  ."ost  things,  as  well  as  '?"'?  ^'"^  '^^'^'^  l^ut, 

"tanner  as  they  pass  over    t     '   1     "'"i^'  "'°  '''''^'  '»  ««'»e 
niude  their  mark."  '  ^^''"^  ''''^y  «4uatter.s  have  also 

The  good  example  of  I),.  'I'l, 
days  of  the  regulL  sett  erne       vTth  "I"', "'"  '"  '''  --'v 
S'on,  is  well   drawn.     "Tl  f  ni  '''^"" '^^  ^'"-Mx'ofes- 

reputation  upon  the  profession  !!'?''  "f,  ^'"'^  -^^'""^^"'un's 
of  thoroughbred  ph-sicia  ;;,'"'"•'  '^  '^  '^^^  ^^-^^^ce 
-hon,  he  had  been  directh'  s  U  i;.;;''"^'"?'^'^-^'  "'-'v  of 
consequence    followed:    mr  eke  v  '"  "^''^''^ting;  another 

Although  quackery  is  inli^eno,     •"'".  "'"l"''''^'''^'"    abated, 
thieving  and  lying!  and  alv':-.'       "  ^"""^'"   ''*^'^'-^' ^^'^e 
the  indirect  ratio^^f  the      S^  "  '  T'''  '''  ''  "°'"''^^'-^  ''" 
of  the  regular  part  of  the"  r    1,^    '  ''T'  ^'-'"'"-tions 
exteiisively  patronized  pln-sci-mtn        ,      '"   ''-"'''"'  ""^ 
<^iplom,.,.  and  the  expeHe        o  V  "'''^  ^'^  ''''  ''^^I'-^ite 
g'-owso  dull  in  diu.io   Attol/r'  '"'^^''"  t'>^'"'-^^']ves  to 
an   hour  before  deat^l    '      1         '      "  ''^^''''^  P''^'^»t  half 
stimulating  through  the  d.uorr'l^""''/'"'  ^^''^'  ^"^  '^<^"^ 
the  dignity  of  theh-  hig^,  e  Hin^     ,f '     '''■'  ""  -'"P-'^-^e 
or  ]M-escribe  'Mother's  kuero"l^,'''''T  ' "'^ ^^'"-'^^"V 
smaller  pretensions    .nd    nn-         T     "'"^  ^'°'"'"'' "'"^  of 
information,  should  "    "  T fT"""  r''''  ^'^  '-"- 

springing  up  around  sul     k    m  .  I   ""'■'"'  '''  ^'"^'^'^-7   ^ 

.ol^sc^-j::-;;:^:;;-^^^^^^ 

five  or  six  cases  of  nio-hf-  ki;,  i  "  t^"ssett  mentions 

Very  full  account  S:^^;^^?":.^-^  ^^^^^^  l-'ge  doses. 

of  the  former  disease.     ]),•    B.,,,2  1         ,  '''''''  treatment 
equipped  librarv  and  }Jlf  "*  '"'^^  '^"^'  '^  ^-^11- 

Hew-ie not  >;  ■'' , rtrf .' """"" ''''' ''' -^ 

.y  ^"}  tun,  but  most  appropriate.     <>In  the 


1 1: 


i.  'ii 


I  '  t! 


14 

sprin-  of  1833  we  Avero  visitetl  by  the  scarlet  fever  in  its  most 
iiiiiliynaiitforni;  during  tlie  ])reviilence  uf  this  epidemic  more 
than  fifty  infants  perislied  in  Huntsvilie,  iit  the  only  age  they 
are  not  an  annoyance  here.     I  treated  nine  bad  cases,  and  four 
terminated  fatally;  I  lost  nearlv  half  in  almost  everv  instance 
An  older  i)ractitioner  was  called  in,  but  I  am  not  certain  that 
111  their  own  proper  practice  they  were  more  fortunate.     In 
more  than  one  instance  there  lay  more  than  one  dead  child  in 
the  same  house  at  the  same  time.    I  feel  certain  that  this  was 
a  most  malignant  disease;   but  I  do  not  feel  certain  that  in 
every  case  our  best  physicians  remembered  the  united  counsel 
of  Hippocrates  and  Ovid,  that  -nothing  does  good  but  what 
may  also  hurt,'  and  which  should  never  be  lost  sight  of  by 
the  man  of  medicine." 

The  following  is  an  extract  from  the  account  of  the  'small- 
pox epidemic  of  1835  ;     -  My  treatment  was  prettv  much  that 
laid  down  by  Dr.  Meade:  bleeding,  gentle  aperients,  cool  air, 
sub-aoid  drinks,  mild  anodynes  and  vitriolic  infusion  of  barks. 
Although  the  purgative  j)art  of  this  treatment  embroiled  the 
faculty  of  the  early  part  of  the  18th  century  to  such  a  degree 
that  the  like  has  not  been  heard  since  the  days  of  Guy  Patiu 
and  Antimony— shaking  the  authoritv  even  of  the  celebrated 
triumvirate,  Mead,  Friend  and  liadc'litfe,  and  who,  on  their 
part,  embalmed  one  Dr.  Woodward  in  their  gall  and  handed 
him  down  to  posterity,  like  a  'dried  preparation,'  as  a  speci- 
men of  the  folly  of  small  men  who  attempt  to  run  against 
'the  throned  opinions  of  the  world '—and  a  proof  that  -polite 
literature  does  not  always  polish  its  possessors '—yet  we  of 
Huntsvilie  were  too  willing  that  our  brethren  should  have  our 
cases,  to  question  each  other's  practice." 

Dr.  Eassett  states  that  among  the  30,000  inhabitants  of  the 
county,  thirty  physicians  practiced  who  were  paid  about 
^50,000  a  year,  <■  which,"  he  says,  -is  but  bread,  and  scarce  at 
that  -;  and  when  we  contemplate  the  50  lbs.  calomel  and  1000 
ozs.  (piinine  which  they  swallow,  it  reminds  one  of  Falstaff's 
bill  uf  fare:  "But  one  half-penny  worth  of  bread  to  this 
intoleraole  deal  of  sack." 


r  in  its  moat 
lidomic  more 
Illy  age  they 
ses,  and  four 
ery  instance, 
certain  that 
rtiinate.  In 
ead  cliild  in 
hat  this  was 
•tain  that  in 
ited  counsel 
•d  but  wliut 
sight  of  by 

f  the  sniall- 
r  much  tliat 
ts,  cool  air, 
on  of  barlvs. 
ibroiled  the 
ell  a  degree 
Guy  Putin 
;  celebrated 
0,  on  their 
ud  handed 
as  a  speci- 
iin  against 
hat  'polite 
-yet  we  of 
Id  have  our 

mts  of  tlie 
)aid  about 
d  scarce  at 
1  and  1000 
'  Falstaif's 
id  to  this 


There 


IS  a  very  clever  d 


debated  question  of  th 
following   is  a  good   evtr 
science  to  have  to  st 


18 

'■^cussior  on  th 


'^  "^(-'  of  anae; 


0-  :it  that  t 


'act :    "  li; 


ithet 


I 'ill',  muc.'i 


'i-'s  in    lal 


dull 


11  ess  of  the  cl 


op  and 


IS   truly  hu 


lor, 


truth— to  see  sucl 


^'■i.7  can   fra 


'■•-'■^f  upon  her  cou 


sto])ping  in  th. 


'  "  "laii    us    i) 


nie  an  excuse  f, 


The 

niiliating   to 

I'Sf  until   tlie 

or  an  obvious 


side. 


"-^  '"idst  of  jiis  h,l 


■ko  a  monk  of  the  fif 


!iO)\ 


Nmi.sou,  of    Kdinbur-h 


prove  a  truth  at  mid 
hy  practice  in  th 


(lav. 


I'v  ai 


risi^  of  losing  l,y  nio-i 

Let  I 

Ilebr 


e  nioriiii 


It  u- 


loj)  logic  bv  tl 
teenth  centurv.  to  end. 
"""■"t.  which  he  had 


iuid  th 


"■  'le  had  earn 


*-'''L'by  riinni 


"g  at  lea 


le  Way- 
avor  to 
pi'oven 


St  a 


"s  examine  in  plain  Kndish  h 
••e«'  authority  for  the  ,^, 


fd  thr.M.gh  the  d 


'f  '"■'"■  translation  of 


IV. 


getting  one  dent'  out  of  i 
another  in." 

At  the  head   of  tl 


I'f  chlorof 


tht 


I's   turtle 


S     {.nri 


'"■'"  and  see  if  i. 


he  d 


'oes  not  put 


volume  of  1- 


en  lie  r's 


"'  article   l,y   D,..  j 


\{ 


tliought  it  better,  in  doubtful 


■ports  stands  t: 


>"-^^i--tt  in  the 


th 


quotation,  "C'eh 


second 


iin  none  at  all  ";  w|,ieh  1 


foil 


ence  and 


^''^^-^.totrya.loubtfulremed 


owing  vigorous  style:    -J 
'  opinions,  1  desire  to 


't'  quotes  only  to  cond 


:i  villi 


my  individual 


us 
"in  in  the 


ciiee  ana  opinions.  1  desire  in  /  -  '"^"^'I'l'al  ex 

«.e  lest  i„.™„,  ,,;;;  ;»  ™-.;-.o,,.     ,,    ,,,^ 


lis  charitable.     I  ujl 


'late,  in  my  own  ],|.actic 


fortu 

the  head  of  tli 
iu  the  eyes  of 
and  it  is  not 


heref 


Host,  and  exjierience 


peri- 
')  cases 


ore  oiilv 


hut  rend 


say  that  I   have  1 


ers 
•een 


I'^iii'ticle.    That  rule  of 


^y'/yersing  the  aphorism  at 


that  have  opposed  it  I 


every  generation  of  both  ,1 
^^■«'Hlerful  that  the  feu-  abj 


Pi-actice  has  found  f 


iivor 


French  expect 


!i"ve  warre.l  in  vain,— that 


octors  and  patients 
le  men  of  everv  ao-e 


lave  ahk-e  failed;  d 


"cy,andthequackervof  ( 


the  science  of 


'When  phvsici 


;  tiyingiiieii  uill  1 


■  ei 


'man  honia 


follow  the  dictates  of  H 


Ills   were  re.piired.    1 


nive  pills  and  | 


ojia 


•thy, 


sors,  us  closelv 


'IS  Cliristi 


OSes  and  tl 


ippocrates.  and  h 


mandments  of  3[  _ 

to  act   boldly   their    faith 

opinion  sustained  them;  and  h 


;iarson5 

ic  opinion,  to 

s  immediate  succes- 


'.V  luibl 


ans  lunv  ])rofess  to  follow  th 


prophets,  thev  cl 


111   these   autl 


iiimed 


e  com- 
!i  right 
'S»  and  public 
>«'ever  uitlicuit  the  task,  thev 


loritie 


1 


found  it  much  eiisier  to  unilorstiinil  the  written  liiiigiiiiye  of 
llippocratf-s   tiiiiii  the  yet  iiiuru  obscure  toiu;liiiii,'s  of  Nature, 
Itetwei'U  wiiic'ii  iuitl  iiis  followers  lie  stood  au  iufallilile  inter- 
preter,  inalxiiig  lier  mysteries  so  jdaiu  tliiit  wayfaring  men, 
tliougli  fools,  ciiuid  not  err  tiierein.     llii)poenites  was  but  our 
fellow-servant,  and  we  are  but  ministers  of  >;ature;  our  wliolo 
art  consists  in  understanding  her  language  and  laws  ;   our 
whole  i)ractice,  in  obeying  her  nnuuhites  :  if  we  do  not  under- 
stand them,  it  is  either  our  fault  or  misfortune;   to  act  as 
though  wo  did  is  quackery.     Celsus  says,  this  bold  practice 
of  old,  fere  tjuos  ratio  non  restiluit  temeriUts  adjurat;  but 
shrewdly  remarks,  that  'Physicians  of  this  sort  diet  other 
men's  patients  more  liapi)ily  than  their  own.'     1  doubt,  how- 
ever, if,  in  the  present  state  of  medicine,  u  thorough  physician 
is  ever,  in  any  stage  of  any  disease,  so  completely  without 
rational  education  as  to  be  thus  non])lussed,  iuid  driven  to  the 
necessity  of  dealing  a  blow  in  the  dark ;  where  there  are  no 
intelligible  indications,  it  is  clear  there  should  be  no  action." 
"Then,  if  1  have  not  followed  the  advice  of  this  master,  it 
has  not  been  liglitly  laid  aside;  nor,  as  1  have  stated,  without 
precedent;   anil  if  [  have,  in  a  measure,  adopted  another  of 
his  rules,  to  nuike  food  physic  (optimum  vero  medicanientum 
est,  cibus  datns),  it  has  not  been  upon  his  mere  authority.     I 
revere  authority,  believing  with   the  royal    preacher,   that 
'whoso  breaketh  a  hedge,  a  serpent  shall  bite';  yet  I  rejoice 
that  its  fetters  are  broken  in  iiiedicine — that  we  no  longer  are 
hedged  with  the  eternal  cry  of  '  Ilipjiocrates  and  reason.'    Hut 
if,  in  getting  rid  of  the  authority  of  the  Ancients,  we  have 
discarded  the  example  of  their  labor  and  learning,  and  turned 
a  deaf  ear  to  their  opinions,  it  is  easier  to  be  lamented  than 
corrected.     If  the  unthinking  part  of  the  profession  of  old, 
that   followed   authority,  and   'on  the  first   day  of  a  fever 
loosened  the  belly,  on  the  next  opened  a  vein,  on  the  third 
gave  a  bolus,'  etc.,  are  now  represented  by  those  who  follow 
fashion,  and  give  calomel,  quinine  and  cod-liver  oil  every  day, 
we  have  but  changed  authority  for  fashion,  and  are  yet  h\ 


liin^fiiii,!,'o  of 
,'s  of  Nature, 
'iillihie  iiitor- 
yfiiriiiy  luc'ii, 
1  WHS  hut  our 
e;  our  wliolo 
il  liiWfj ;   our 
o  not  uiidor- 
c ;   to  net  ii8 
bold  j)racticu 
idjuntt ;   hut 
t  diet  other 
doubt,  how- 
^h  physiciaa 
tely  without 
Iriven  to  the 
there  are  no 
?  no  action." 
is  nuister,  it 
ted,  without 
.  another  of 
Llieanieiitnni 
uthority.     I 
lacher,    that 
et  I  rejoice 
0  longer  are 


bond 


17 


V-  hutfuHhiou.  ihond. 


wind,  and  if  fo 


ilfsi/s'iiintr  in  its  .. 
Jiiark.-i,  at  whidi  w 


'I- a  till,,..  i( 


indoiiiifiil 


'■'llTlu.S  th. 


'■i'-  '•luinoe.s  xiti,  ,] 


'-■'"•'••■nt.  it  .soon  1 


^^niajl  eraft.  tl 


^''  \veak  or 


fes 


'Sional  nuirtvrduni 


I'  can  at 


least 


Ik'arelv  has  ti 


tifuli 


II-  '•redd  of 


y  exjiressed  tin 


a  Xr;il( 


til  at  tile  study  of 
relates  to  medicin 


■"   III    ihe  foil 


f 


oreinn  Ijij 


i.i,''!!!^^',  and  wj 


natun 

<■'>  is  an  casv  t 


K:::;'"":'r^''-"'-'.a.]and 

''".^''''  ^vithout  f.ar  of  pro- 

'II'  I'i'vsieian  been  n,ore  1 
""•"Iff  words:  -rd 


)eau- 


'"""inandeonii 


o  not 


iisl. 


let  ai 


""'"live,  as  f 


my 


ill'  as  it 


'""  ff"  into  its  n.it 


'^■"  I"-'  thinks  he  1 


"y  ""K'  iindertak 


e  a 


th. 


t-' polite  and  well-iiif 


'^'t'  eoiujtry  and 


"i-i  niastered  it,  j^t 


tile   illiterate   and    rud 


ornu'd  ;  if 


"^'■'"i'f  louse  it  am 


lunatic 
sentences  tin 


"'^y'li'n,  where  th 


U'llen 


'"-'  •'iiLTeed,  Ift  1 


lonjr 


sla 


"'I   i 


iini  '^o  amoui 


"i'''  tlie  mouth  of 


^  vornaeuhir  is  babbled 


•^   t'urrent;    i„to    tl 


le 


'"Hierstand  this;   should 


m 


that  he  k 

calculate   the  cost7in""l 


'"'   ''liot.  and  atte 


"'  "gain  succeed  1 


broken 
nipt  to 


""^vs  that  lan.ua^e      fe  7     "\'"^  "'"^-  ^"^^'^  ^"y 


this  amount  and 


ii''t>i',  time  and   tal 


*•'"  set  do 


wii 


i-'Ut;    tht 


»n  and 


len 


S^Mdlvintothestudv'f    V  '   "'"'"''-' 


»•-'  lias  exhausted  his  pr 


SlUlorry;    ^^^^^^ 


'^"'"''  y  '<"«cking  at  the  doln-  o      .        '"^  "'"  "'»'  '''"'^^If 


opened;  for  dil 


nnikc 


lye'H'e,   like   t 


_*'""';  of  the  tempk,  and 


11  way  throutjh  fi 
our  profession.     \Vl,en  h 
portions  of  the  iute 


'ozeu 


le  18 


All 


le  vjuegar  of   \l 


'■"*'•   It  is  tht 


open 


It  will  be 
iiunihal,   will 


satisfied  with  the  b 


intricate  and  astound 


'■101-,  its  vast  and 


varied  di 


!i"-s  of  a  singular  stahTl 


"Iff  action  of  its  mach 


'S(nnc 
iful 
niension 


of 
]>ro. 
I  the 


larmony  under  th. 
be  anything  second 


ity,  whose 
e  government  of  sec. 


such 


are  not  satish 


.w^  i,uL  sarisueU   unt 

ultimate  object,  to  take  hi 


'7  in  luiture  l-when  1 


suffer 


"  >t'l  informed),  he  will  be  led 


Laz 
thes 


"inc 


th 


'iit^i'y,  obeying 

'es 

re 

•■*  satisfied  (and 

to  ills 


'.'    coiilliet  produt 
'mlary  laws-if  th, 


aruses,— into  th 


'.  lo  taKe  ilk    .w(-  1,  -..          p                ^"-^  ••"  "18 
fevered  ,.r     1    t;°'"  ''■"»■•'- 1«.-  1 


"ii'l   phreiizied,   fr 


di 
lo 


io  magazines  of  mi 
sease  and  sin,  h 
«'iiig  the  e.> 


e  pest-houses   and 


•sery  and  cont 


'O'li    tile   Jobs 
prisons,  and  her 


and 
•e,  in 


I.  ne  must 


not  only  take  uji  h 


'igion,   these  JJabels  of 


ample  of  his   Divide  M 


iJi  abode,  but  fol- 


dwell  there ;-this  is  Kathir'"'      "''"'  '^^'  "'"^^  ^-^^  to 


!| 


!       1 

i  U 

* 

18 

"  When  such  an  one  rc."ntei-H  tlio  world,  he  is  a  pliysioian  ; 
his  viiat  liiimrs  hiive  not  only  tiui^rjit  him  how  little  he  knows,' 
but  that  he  knows  this  little  well,  ('onscions  of  this  viiluoi 
he  feels  no  necessity  of  trumpeting  his  professioiwil  ucfiuire^ 
ments  iibroiul,  i)nt  with  becoming  modesty  undtrue  dignity, 
which  constitute  genuine  professional  pride,  lie  leaves  this  to 
the  good  sense  of  his  fellow-citizens  to  discover." 

Dr.  Hassett  developed  tuberculosis,  and  the  last  letter  in 
the  budget  gent  to  me  was  dated  April  ICtii,  IH.'.l,  from 
Florida,  whither  he  had  gone  in  search  of  health.  He  died 
Novemlier  I'd  of  the  same  year,  aged  K;. 

To  a  friend  he  writes  on  the  date  of  April  r)th:  "This  world 

has  never  occupied  a  very  large  share  of  my  attention  or  love. 

T  have  asked  but  little  of  it,  ami  got  but  little  of  what  1  asked. 

It  has  for  nuiiiy  years  been  growing  less  and  less  in  my  view, 

like  a  rec^'ding  object  in  space ;  but  no  iietter  land  has  appeared 

to  my  longing  vision;  what  lies  behind  me  has  become  iiisig- 

niticant,  l)efore  me   is  a  vast   interminable  void,   but  not^a 

cheerless  one,  as  it  is  full  of  pleasant  dreams  and  visions  and 

glorious  hopes.     I  have  covered  it  with  the  landscapes  of 

C'huKle,   aiul  peojded    it   with   the  martvrs   of  science,   the 

pioneers  of  truth,  the  hound-hunted   ami   crucified  of  this 

world,  that  have  earned  and  then  asked  for  bread  and  received 

a  serpent— all  who  have  suffered  for  the  truth.    IIow  glorious 

it  is  to  contemplate  in  the  future  these  time-bufTeted  at  rest, 

with  their  lacerated  feelings  soothed  as  mine  have  been  this 

day  by  the  tender  regard  your  wife  has  manifested  for  mv 

future  wcll-beiiiff." 

The  saddest  lament  in  Oliver  Wendell  Holmes'  poems  is 
for  the  voiceless, 

"  for  those  who  never  sing, 
But  die  with  all  their  mnsiu  in  them." 

The  extracts  which  I  have  read  show  Dr.  Bassett  to  have 
been  a  man  of  more  than  ordiiuiry  gifts,  but  he  was  among 
the  voiceless  of  the  profession.     Nowadays  environment,  the 


i  pliysiciaii ; 
Ic  111'  knows, 
■  this  virtue, 
mill  ac(|uirc- 
rue  (ligiiity, 
L-'iives  this  to 

ist.  letter  in 

ISAl,   from 

1.     He  (lietl 

'This  world 
tiou  or  love. 
Iiat  I  usked. 
ill  my  view, 
iis  iijiiieureil 
come  iiisig- 
but  not  a 
visions  and 
idscupes  of 
cicnce,  the 
ied  of  this 
II (I  received 
ow  glorious 
ted  lit  rest, 
e  been  this 
ted  for  my 


W 

'•I'lx'rtiiiiiiv  fnv  work  theslirf      r  I 

tl'f  siimmil.     To  (iios'e  ivslioss    .'!     !"'''?  '''"""'"  ''"'''>  '"^•"  '" 

with.MK  ..|.poriMni,i,.<    ..Md  ;,       '        ^^'"'I'uvehadaml.Kiun 

I'fgan  by  Sluing  ,hut  I  w,inld  te  I  vl'r"  ""''  '"'  "  •^"''"•"-     ' 

•n,lH:j«  h,  left  ,.if,,^„,,  ,,,i,,,:j  1'"  '^;'  '•^•v^''v.l.  -Hi  lor  whom 
"H-^  To-diiy  soiircely  one  ,.f  ,  Z.  ,,;^''^'  ^•>-  '•^■"^■''  '^"-vn  to 
."«^vith  anydrmness  from  (h'  .  '''A  '"  "'^•""'""■^  ^"'"'''-^ 
>t   nmy    be   said,    thov   are   us     l         .  ''^  "  "wjority  of  ( |,,,„ 

Allowed,   are   shadow;  I;"  J"'"  /-"'"-  -''O".   i^a.sett 
P<4'il),clragg.du,,t(u^i,,,,,.;  ,:    7'    '"'   "'-''■^"'H.t   us    the 

ncii  who  would  learn  phiiosoph;  i    Sstn'   T ''l""'  '""'^"'■" 
to  have  made  an  edort.  to  h.ivo  1        V    ''    ' « '"'^•'' «'nvon, 

u--uono  are  worth  ti:'x':rr^"''T'' '■'''- 

generation,  one  or  two  sii'it,.!,    .    '""^  ""  '""^  """i"   '"  u 

•n.t  for  tlH.  rest  of  .:    ;      \:::'^';;''«/-- 

and  his  tciichers-ami  ^'"'"'-^ve,  too,  are  with   Uassett 

"no  one  asks 
Who  or  what  we  have  l.een, 
More  than  he  asks  what  waves, 
in     le  moonlit  solitudes  mild 
Of  the  nudmost  ocean,  have  Hwdie.l 
Foam'dforamoment,,an,i,-one'     • 


I ;, 


poems  IS 


'tt  to  have 
ivas  among 
iment,  the 


i: 


1 1  i 


^^xy/7 


ON  SfX  CASKS  OF  ADDISON'S  DISEASE, 


urn  I    II  IK 


DV  I  HI',  I'SK  orniE  SUI'HA- 
liflNAI.  K.VriUCT. 


BY 


"'"-';|AM  „sM.:,t,  M.D.,  i,,«,P,  (r..,,) 

lMf»»,„,,|,,„,l„,,,,„,„„..„, '■ 


ll'ipkiiisCnivcrsiiv. 


$      ' 


^^^Pri'^eajro.  ..  .._,,,„,  ^^^^^^^^  ^^^^^^^_^  ^^^_^^^^^^^  ^^^^^ 


I 


I; 


''  mS?  w!!''^^^^'^  ^^^^^^'^'  ^^™  THE 

^'^  IHL  U8E  OF  THE  SLTIU- 
J'RNAE  EXTHACT. 


r.i 


N'iNK  cases  of  tin's  nr,.  off    »• 

two  of  tl,ose  I   .na^rr  :^r   nr  '''"  ""''^■-  "•^--va.io.. 

tie  Transactions  of  the  PhUadcluhia   Pm'l  i  '*"  '"  '''*'""'«   ■^••■''■-  of 

six  oases,  which  1  here  give,  h  v        t  ,      :  ;''''^'  "t'''     ''''  ^'''''''--l 
Recent  studies  ren<ler  it  vp..  !  f     i'''^  •"•-..sly  reconled. 

i^co.ect,-na.e,,,th^th::^.::::^yrr^'^ 

function  of  the  a.lrenals.     Th'o  eviTn  ".''"^'  ''''  ''''^'''^  ''^  loss  of 

available  i„  the  elaborate  GonKio  r  Z  "'""''.  ^'"'^  '^  ^»-''  '^^  '"^a'lily 

dress  of  Professor  Sehafer  '  .     J         '  ,  'C';'"  ''  ''""^■^'''"'-'  "'  ^l-e  a<N 
Oliver.*     On  this  view  the  <lis  a      fa     ,  '"'";  ""'  '■"  '-^  I'"'-  '>v  ^- 

and  is  caused  directly  bv  the  itsf  t      '"l'' '"  I'"  -P-ts  to  „,yxa,den,a, 
The  comparison   between  thes    to  d   e       T    T""""'  ''  ^''^  ^^'«-l« 
As  far  backasl88o,i„a„a    icle    n   nr  ^'V^''^^"-^'>'  '-en   drawn, 
te..  c^Medicine,"^  I  nsed  the  llllt:;^'    i:!!::^  '"^-^  '"  ^'^i'^-^  "  %«- 

'The  relation  of  affections  of  the  thvr,  i  l"    .      , 
cret.n.sm,  and  the  experin.ental  pro  1  , el,-  .1  ""     '"  '"•^•^^''^'"'v  and 
-val  of  the  thyroid,' have  JlZ^T^     ^H  ^""""""  ''  '''  ''- 
ductless  glands.     It  is  interestin.r  to  n!     ..  "uportance  of  the 

and  Addison's  disease.  H  f  the  t.  V"-''T  ""'''''''  "'-^-'--^ 
the  tissues-in  one  an  increas:;!;  'II  tZ;'''''^:^  ^'^^^  '» 
p.gment-and  in  both  marked  nervous  ,1  '  ""  '"''"^^-^^  '""  tl'e 

gressive  dementia  in  nn-xa.dem.rrZr';'''"?'-"  '"'"'»'  •'"'"-^'  ^  l-O" 
We  regarded  the  thyroi/^  ^  ,;::^';:  .r''^"  f  J"  '^•'^''-"'^  «"-se. 
geons  and  extirpation  in  monk        b    H  J"  ''''''''"^•*^  "^  ^"•- 

of  its  function  was  followed  by      seHo's'T:  7  'T''"^''^'  ^''='^  =''"'iition 

tl.e  experimental  removal  ofr^:„dr;:r''"'"^^  "^ 
closely  allie<l  to  man  than  the  anim  d    hm     .      ""*" '!^->''^-«"  ■""^'1'  more 
demonstrate  that  these  little  bod  et  .^fPenmented  upon-nuay 

health.  "  '  '^'''''*'  '"'  "'-^^  ""t  ^^-''''""t  their  influence  upon 

__^Althoughjhe  viewof  disturb.nnnervatio.^.e,uent  upon  involve- 

'British  Medical  Jourr.al,  1895  vol  ''  ^"'"'^'P'"'^-  Series  iii.,  vol.  viii. 

^  British  Medical  Journal;  1895;  lot  U,  \  t^l^;  '^^^-  "" 


iv  <4 


^^^l 


^ 


91 


WILLIAM   OSLEU,    M.D. 


niont  of  tilt'  abdominal  sympathetic  meets  the  case,  theoretically,  better  than 
any  other,  ant!  is  at  present  widely  held,  yet  there  are  signs  of  a  return  to 
tlie  old  view  of  A(hlison." 

The  analojiy  will  be  complete  if  it  be  found  that  in  suitable  cases  the 
use  of  the  suprarenal  extract  cures  Addison's  disease  in  the  same  remark- 
able way  that  tlie  thyroid  extract  relieves  myxoedema.  Clinical  workers 
may  now  <'ontril)nto  their  share  by  carefully  studying  the  efTects  of  the 
extract  in  selected  oases.  Addison's  disease  is  so  rare  that  every  opportunity 
should  be  seized.  At  the  same  time  the  greatest  caution  should  be  exercised, 
on  the  one  hand,  to  .select  only  well-characterized  cases,  and,  on  the  other 
hand,  to  exclude  cases  in  which  the  conilition  is  a  concomitant  of  wide- 
spread tuberculosis. 

Cask  I. — Fi'.i ling  health  for  a  year;  attacks  of  faintness;  bronzing  of 
face  and  iiands  ;  sudden  death.     (Abstract.) 

A.  J,,  agoil  about  forty,  lawyer,  consulteil  me  in  the  spring  of  1885,  complaining 
of  weakness  uiid  attacks  of  faintness.  He  was  a  healthy-looking,  well-nourished 
nnin,  of  (jood  family  history.  For  about  a  year  he  had  been  overworked  and 
worried,  and  hiul  had  at  times  dyspepsia.  On  one  occasion,  in  court,  he  felt  very 
faint  and  almost  fell.  On  two  or  three  other  occasions  he  felt  very  weak  and  jiros- 
trated  without  any  obvious  cause.  I'or  nearly  a  year  he  had  noticed  a  gradual  dark- 
ening of  the  »kin  of  the  face  and  of  the  hands.  At  the  suggestion  of  his  physician 
he  sought  an  opinion  as  to  the  existence  of  Addison's  disease.  The  patient's  gen- 
eral condition  was  so  good,  without  ansemia,  loss  of  flesh,  or  any  signs  of  tubercu- 
losis, and  tlie  pigmentation  was  so  sligiit  and  limited,  that  doubt  seemed  reason- 
able. Dr.  I'oppcr  saw  the  case  with  me,  and  we  agreed  that  the  pigmentation  and 
causeless  faiiUing  spells  were,  to  say  the  least,  suggestive,  and  we  advised  him  to  give 
up  business  for  a  year  and  live  quietly  abroiid.  He  went  home  prepared  to  follow 
our  advice,  arranged  his  affiiirs,  and  made  preparations  for  his  trip,  when  one  morn- 
ing he  dropped  dead  in  a  railway  station.     There  was  no  autopsy. 

Casio  II. — Gradual  asthenia  ;  progressive  bronzing  of  the  skin  ;  attack 
of  syncope ;  nausea  and  vomiting.  Autopsy  :  chee-sy  foci  at  apex  of  left 
lung  and  in  bronchial  glands;  tuberculosis  of  the  adrenals;  very  slight 
matting  ol'  the  .semilunar  ganglia  and  nerves. 

Xellio  U.,  aged  forty-one;  admitted  to  the  Philadelphia  Hospital  July  2,  1886, 
with  great  weakness  and  bronzing  of  the  skin.  Her  father  and  mother  both  died  of 
lieart-disease,  one  sister  of  dropsy,  and  one  of  heart-disease.  She  had  small-pox 
when  a  child  ;  otherwise  she  has  been  a  very  healthy  woman  until  a  year  ago,  when 
she  was  attacked  suddenly  with  great  pain  in  the  region  of  the  heart  and  with  dysp- 
noea. The  distress  lasted  for  at  least  three  days.  Until  April  of  this  year  she  has 
been  in  fairly  good  bealtli,  excejit  that  she  seemed  more  languid  than  formerly  and 
felt  indisposed  to  work. 

Lust  November  her  friends  noticed  that  she  was  changing  in  color,  and  througb- 
out  the  winter  her  normally  fair  com|)lexion  has  been  replaced  gradually  by  a  dark 
bronze.  Three  weeks  before  admission  she  hsd  a  sudden  attack  of  syncope,  pre- 
ceded by  di/./.iiiess  in  the  head.  Shortly  afterwards  she, began  to  vomit  after  meals, 
and  has  done  so  almost  every  day  since.     She  has  had  no  pain  anywhere. 

J'lfKnil  Comittioii. — Small,  somewhat  emaciated  woman.  Face,  neck,  and  hands 
deeply,  general  surface  of  the  trunk  slightly,  pigmented.  The  bronzing  of  the  face 
is  extreme  J  it  is  interesting  to  note  that  on  the  forehead  the  deep  small-pox  scars 


SIX   CASKS  OP   A 


odiso.n's  DISKASK. 


are  unpigmented.    The  skin  of  tl,,.  .,iwi 

the  finger,  are  not  clubheu  "  U^ '"''"'^'"■'^'" '''""''''""'•''- '''"-x 
thready;  the  heart-sound.  ar;  el  .:,;';?'""'■  '.''?  ''"'-  ^  »"-  -"all  and 
chivKdes  at  botl.  apices,  and  the  percu  s  ,  1  '' r'V  l*"'"  """*'"'"^'  '"'"'^""'  'he 
a  fcw  rales  on  deep  .nspiration.  Tl  ,  "  ^r"  ^  '  '''"''  '""■'"'''  '''"'  ''""•-'- 
theep.gastriun^- no  tenderness  on  e,£r::r'  "?'"""  ^"'  '''^"lM"-e.ssure  in 
mentation  of  the  n.ueons  nienihru       ?,  "  ■"""''  "■'«'""'•     ''"'"''•e  i^  >'o  pig- 

good;  noana.niia;  temperature  98=' F  '"""''     '■^''"  ^"'"'' "•' 'he  lips  is  (airly 

Tlie  patient  had  most  profound  ■n,nr„v  •       •  ■ 
twice  vomited  small  quantities  of  hlood      s.J"  "''!     H""'"'"  f^'""^'^^'""""-  ''-1  once  or 
^«fe;«y.-liody  not  emaciated  ■  skin  olf '      '  ^""'^'  '"'^'  '''•-'''  '^"  '''^  13th. 
bronze  eolor;  marked  pi.mentatio;,  of    ij  J;  ;' ^^f ,  '-.'''^  -"'  arms  of  a  light 
a  dark   patch  on  either  side.      V.„.i„,        ,  "  """^'"  ■'^"'•'a^'es  of  cheeks 

abdomen  three-fourths  of  an  inch  ilrthic'kneT''  "'"  '''*-""''"''^'';  Pa"niculu.s  over 

Periloneum. — Adhesions  betw        tl 
The  omentum  is  adherent  to  the  wall  of'thenT-"'" 't'  "''''  ''""'  ^'"^  diaphragm, 
at  the  right  apex  and  general  adhe       l'  ^^,  e  "a  sil"  "'Ti"  .''"^  ''""  •■^'"'-'"- 
blood  and  clots.     The  valves  are  normal-  M\r  I"'     ^'''  '"''"■'  '"■""""■"^  fl"id 

Zu«y..-The  left  is  crepitant  ex    i'.'  '"''^'''"'■'  "  ''  ""'*-  P"'-- 

areas  of  anterior  margin,  which  si,;,  v    i  ^sv  f kr*:,  '"^ '' "^ ';"!'', '""  '""  "^  ^'^^  -''-^ll 

tion.    The  right  lung  is  evervwhere  c  e      .    t     Tl  ■""T""'"'^^  ^y  S^'"''"""-^  i"filtra- 

at  the  apex.    The  bronchiafglands  are  caseous         '"■"'  "  "''^•'''^"'^''.  Particularly 

Stomach. — Everywhere  tliron   I      t\ 

two  millimetres  in  diameter.   The.^is",  i.mlT  r""'  *"■'  """"   "'''^^   ^^"""^-^  about 
and  no  other  special  changes.  l"g'"<^"tat.on  towards  the  pylorus ;  no  erosions 

The  spleen  is  of  average  s!7p    n^r^.„^       n 
looka  „o„„al.  •        "•  ''"""'>  •■«""■"■'"  ■»  tl'e  <llapl,n.g,„,  „„,1  ,l,e  |,„|p 

but  In  'tL'^dlJrbrol;  Z''rMu  l2,'r°w''r  •"»■''"*"»■    Tl.er«  .„  „o  tubercle,, 
p.t«l,e,  and  the  .olitar,  ghtuj'  ^     '"""  ■''  "''»''"  «"l«'S"»eut  of  l' ej-er', 

apeciall,  involve,!  i„  cic  t,         t ;  ,f  f  rX '"  J  "  rf''  "'"'""'■  "" ''  ^^  "« 

sule  presents  no  trace  of  norn.al  g       ,      1   '    l"'  o w      1    ,'!■  •  "'"'  ""  ''^'''  ^^P" 
cheesy  mass,  the  central   portion        1      ,  ''""  "  "'*="'''''J  l^^  '■»  '^--ge 

tissue.    The  remainder  o|';;\''\';"^^  ^^^'^  '--'"-"t,  fibrous 

«.nall  cheesy  nodules      I5eh    d    hf  ^  "''       '  '""""'"  ''"^"'^  ''"  ^^''"^■b  are 

left  capsuleVe^cntTa  I^X^  'Zri:^:Z:'Z  ]  '"''  ''-^  ■""-   ''- 
organ  is  flat  and  made  up  of  a  gr^-,  transhritX'u:;:"  ^^'"  ^"'"«-    ^'^ 

Ine  kidnevs  are  of  averurp  «i.y^o     ti,     i  r/  "^  ■"'"«. 

and  one  or  two" caseous  nasse^l'i'  '"■'''"''  ""'""'""^  ■'^'""11  ^"I'^rcles 

sules.     In   the  pe Ivl  t  e  b  o.  "'"  '"       "  ""'"'"'^■^  ^^  "'«  ^"''^"'•^"«'  <^-'^P- 

togetherbyo.d;:eri;:,,eil;;,:::il;f"'^'"'"'  "■'^"^^'  -"^  '"^-  --  ^'->'  -"'d 
lege  o?pSS::i";hn:;5:ir'  ^'^^""^  '^ '-  ^"^ '''''- ''---  °^  ^^^^  ^°'- 


I  i   ■  -l 


ll 


4  WILLIAM   OSLRR,   M.D. 

Case  III. — Dyspepsia  and  occasional  attacks  of  vomiting  for  two  or 
three  years  ;  '"or  some  months  gradual  pigmentation  of  the  skin  and  mucous 
membrane  of  the  mouth;  attacks  of  dizziness;  extreme  prostration  and 
antemia  ;  profuse  diarrhcca;  urgent  vomiting;  death;  no  autopsy. 

William  S.,age(l  fifty-nine,  longnhoreinan  ;  admitted  June  30, 1887,  to  the  Phila- 
delphia Hospital,  complaining  of  vomiting  and  great  ])rostrati()ii.  With  the  excep- 
tion of  yellow  fever,  in  18()4,  iie  had  enjoyed  very  good  health  until  three  years  ago, 
when  he  began  to  have  dyspepsia  and  occasional  attacks  of  vomiting.  He  has,  how- 
ever, kei>t  at  work". 

For  many  months  past  (he  does  not  know  the  exact  time)  he  has  himself  noticed, 
and  his  friends  have  remarked,  that  he  was  becoming  very  dark  in  color.  Eight 
days  before  admission  he  had  an  attack  of  dizziness,  in  which  he  fell  but  did  not  lose 
consciousness.  Since  then  he  has  been  extremely  ])rostratcd  and  the  attacks  of 
vertigo  have  become  more  frequent. 

Condition  on  Admission. — Large,  well-nourished  man;  slight  oedema  of  the  feet. 
Skin  of  the  face,  neck,  and  hands  of  deep  mahogany  brown.  General  surface  of  the 
body  very  much  darker  than  ordinary;  sclerctics  are  pearly.  The  lips  are  pale, 
and  there  is  evidently  marked  ana'mia.  Mucous  membrane  of  the  lips  and  inner 
side  of  the  cheeks  deeply  pigmented,  and  a  large  patch  can  also  be  seen  on  the  soft 
palate. 

The  lungs  are  entirely  negative:  no  rales  at  the  apices;  no  dulness;  no  sign  of 
old  tuberculous  disease.  The  apex-beat  is  in  the  fifth  interspace.  Pulse  90,  small. 
There  is  a  venous  hum  in  the  vessels  of  the  neck  ;  no  luemic  murmur  at  the  base  of 
the  heart. 

There  is  marked  pain  on  pressure  over  the  tenth  and  twelfth  ribs  on  the  left 
side;  none  on  the  right.  The  blood  showed  the  characteristic  features  of  an  extreme 
ancemia,  and  the  blood  drop  looked  very  watery.  The  count  gave  one  million  red 
corpuscles  per  cubic  millimetre.     Proportion  of  white  to  red  one  to  four  hundred. 

The  patient  sank  rapidly  after  admission ;  had  profuse  diarrhoea  and  urgent 
vomiting,  and  died  July  6.  The  temperature  ranged  from  98.2°  to  101.4°  F.  So  far 
as  could  be  ascertained  from  the  patient  himself  and  his  friends,  there  had  been  no 
tuberculous  disease  in.  his  family. 

This  is  the  only  case  of  Addison's  disease  which  I  have  seen  witli  pro- 
found anasmia,  a  symptom  on  which  Addi.son  laid  a  good  deal  of  stress.  In 
a  majority  of  the  ca.ses  the  blood  count  does  not  fall  below  fifty  or  sixty 
per  cent.  A  difficulty  sometimes  arises  in  the  diagnosis  of  the  disease  in 
cases  of  severe  anaemia  of  the  progressive  pernicious  type  which  have  irreg- 
ularly mottled  pigmentation.  I  have  recently  .seen  a  case  in  which,  with 
the  progressive  ansetnia,  there  was  a  degree  of  asthenia  and  gradual  pig- 
mentation highly  suggestive  of  Addison's  disease. 

Cask  IV. — Gradually  developing  languor  and  asthenia;  frequent 
attacks  of  causeless  vomiting;  progressive  pigmentation  of  the  skin;  con- 
vulsions; toxjemia ;  death.  Autopsy:  sclerosis  and  atrophy  of  the  adre- 
nals ;  no  tuberculosis. 

David  A.,  aged  fifteen  and  a  half,  a  patient  of  Dr.  Mullin's,  of  Hamilton, 
Ontarii),  who  consulted  me  by  letter  about  him,  and  who  very  kindly  sent  me  the 
suprarenal  capsules  for  examination. 

The  patient's  father  died  at  forty-five  from  pulmonary  tuberculosis  of  four  years' 
duration.    The  mother  is  a  healthy  woman ;  the  brothers  and  sisters  are  healthy. 


SIX   CASKS   OK   ADDISON'S   DISIUSE. 


The  boy  lind  siifTured 


until  tiie  onset  of  tl 


I'roni  no  serious  ij 


>e  present  illnc 


whieh  he  was  confined  to  bed  1„. 
he  iippearcd  to  be  sunburned,  luid 
too  long  in  the  spring.     JJ 
to  apply  himself 


"f'ss  ineurly  life,  and  bad  good 


or  two  d 


I"  .Mareh  lie  had"  a  s!i.r| 


iiy«.     Karl\ 


It  fol 


liealth 


to  study,     Ka 


e  seemed  ai 


»be  tliougjit  it  was  du 


in  April  bis  mot! 


fbriic  attai'k-,  in 


reqi'ently  ,„,  account  of  the  scold 


Ills  of  three  or  f 


fretted  and  cried  t 

March  he  lias  had  at  interv...., 

brought  up  greenish  and  yell , 

the  mother  noticed  that  the  skin  "be 
lent  and  took  b 


■riv  in  tl 


so  languid  and  listl 


>•  to  wearinjr 


licr  noticed  that 


'('  summer  he  was  m 


ess,  and  did  not 


Ills  Scotch  car 


■en  Iron  sch 


f^cem  able 

!is  he 


ow  matter,  aft 


"iir  weeks  attacks  of  v 


"{,'«.     Ever  since  the  attack 


lit  little  exercise  and  did 


fame  much  more 


'■  "liich  he  felt  better.     In  tl 


■oiniting,  in  which  he 


was  fair  and  his  hair  of  a  light  color  ami  ,1 
ened  through  the  sum 


not  en 


iin 


liseolored.     lie  w 


and  sometimes  acted 


nicr,  was  very  niark( 


His  final   il 
statement  in  full. 


stranwl 


y,  iis  if  silh 


'Siige  in  any  sp.jrts.     Hi 
«"  tiiat  his  discolorat 
He  bail  at  t 


ic  summer 
iis  very  indo- 
s  complexion 


ion,  which 
iiiics  very  severe  lieadad 


ache. 


ness   is  so  graphicallv  d 


escribed  by   Dr.   M 


'On   Jlonday  of  tl 


ills  week 


be  complained  of 


■iickness 


"llin  that   I  give  his 
id   beadii 


Wednesday  he  did  not  rise  from  bed- th.it  ni,ri,t  1      >     ;■'••■■■•   ■iuaoacne.     un 

Thursday  he  was  langui.l  and  st    -e'd    i    b  d  •'"?  "'"'  '"''  ""'  '^""''''^'i"'     ^>" 

he  had  no  headache,  but  had  a  1  a^  te  1  '  '"l"'/,"'  "  ""'•-'  ^'^'^^"  ""^"^^  ■  ^-'^'i 
strange,  and  he  acted  as  if  he  did  „,!'  vi'l  ,  7'  '  ''T*^  '"•'"'-'■  =  '''"^  'y^''  ''l'l"--="-e.l 
little  oyster-soup  ;  this  was  .  k  h  ''''  '!'''''''''■    -^'^-"  ^  v.m.  he  'took  a 

later  he  vomited  slightly,  Abo:t  ,"'•',  :;:':;;:"'-'''  "  """-^- '"' ^'-"-1  ; 
the  wall  as  if  he  wished  to  sleep  \  11,  i^  ^v<.uld  not  answer  .,uest,ons;  turned  to 
violent;  the  limbs  were  fixed  ■  he  wis  ,    l,o  'v""  "  """^"'^i""  occurred,  not 

slight  frothing;  thehandsjerk^irii!  I  '  IfrrT''rf"'  '  ""''^  ''^""''  '""' 
'yes,'  'yes';  he  would  put  out  his  ton'  e'an.^r  '^"\  ""'  'i^'^^^^'^'^^V^  to  say 

and  moved  to  the  back  of  the  bed      w!  '  '""""''  "'"^  "'«"  ''"•"'■•!  "^vay 

by  a  physician,  who  said  h  tl  Los-  n  ents  w  ""  '""^.^  '"'  ''''''''''''  '^  ^'^  --» 
cal  patient,  I  saw  him  at  n  o'Zk  t  n  '  '"''  ""'""" '°  ^'"'^^  °''  '^"  ''>'-^'"'- 
but  did  not  seen  able  to  fu  t.  d  r  ta  1  H  '  ""T  ,"'  "'"  ""'  "~-'-. 
request,  but  soo.i  turned  and  m  ed  tt  le  w  1  'T  "\  '"' '™"'  '"  ""'  ^^'^  "'  "'^ 
be  counted  at  the  wrist ;  the  hands  wltl  It  '  ''"'''"'"'  ^''^^'  '"'''  ^'""'^  "°t 
fallen  one  degree  since'taken  f  e  ,e  c  , mds  Z'^Tr'"  '"  ''-^""''  ''''  ^' ' '  ''^  '-^ 
yellow  ;  the  breath  seemed  foul,     Dt^    n        e    i  I  1  ""'"'  "'"  '  ""'^  ''""'^''' 

side  to  side  and  pulling  the  bedelod.e       II    .    '  "''~  '''''^''''  ""^'"^  ''^•"^ 

for  the  vessel.  'L  nett  n.or  igvtued  i .:';;:' "'1^'? '  '1 ''''  "*"' '"  ''''''' 
nails  blue ;  pulse  so  feeble  that  it  eonb  ,1  ,       '  ''""^'  '""''  '^"''''  '^''"«''. 

i32p.minL.  oc.sion:;;;^:r ::l^;^:;:^^ 

and  anl^c^:;':  ■  :i:t;:^:";,;^'  t^^'"  7T  "-•^^^  -  t'-  '^ee,  the  shoulders, 
deeply;  the  itUegumentsX^ 

areola  around  each  nipple  wL  dL^r  "7  T^Z^'  IZ^'^'"'-'  '"'"  "^ 
cesses  from  the  level  of  the  scapular  spines  to  the  s  u  r  m  1'  ^  ''""""'  '"■°" 

the  size  of  a  quarter  of  -i  dollar  mor.    1         1  "  '"'^  "*  ""'  ^''"'^  "'^""^ 


il 


6 


wii.i.iAM  osi.Kn,  M.n. 


(lel|)liiii.  Unfortunately,  tlie  s|ii'cin)ens  and  sectioni  of  both  this  and  tlie  following 
Citst>  iitive  been  nii.slaid.  Both  capsules  were  extremely  small,  not  half  the  normal 
size,  anil  surrounded  by  muuli  Cat.  They  were  firm,  and  on  section  showed  no  dis- 
tinction between  tlie  medullary  and  cortical  portions.  .Microsco|)icnlly,  there  was  a 
condition  of  dill'use  sclerosis,  with  here  and  there  areas  of  fatty  dcKencratiou.  There 
was  n(»  tuberculosis  of  the  or};ans. 

Cask  V. — Attacks  of  voinitinji;  and  indii^'ostioii  for  eijrlit  months; 
gradual  |iiginentati()ii  of  tlio  skin;  intcnst'  prostfation  ;  deatl).  Autopsy: 
tuberculosis  of  l)otli  adrenals;  no  involvement  of  other  organs, 

William  I?.,  aged  nine,  a  patient  of  Dr.  William  E.  Parke,  of  riiiladelphia.  Pa. 
The  boy  was  at  (iirard  Collefre,  and  according  to  the  doctor's  statement  he  had 
seen  him,  on  and  off,  for  about  eight  months,  during  which  time  he  had  been  re- 
peatedly admitted  to  the  infirmary  with  attacks  of  vomiting  and  indigestion,  occa- 
sionally with  a  mild  tonsillitis.  His  color  had  changed  and  lie  had  become  very 
much  bronzed,  but  this  was  suggested  to  have  been  due  to  a  dark  ancestor.  His  last 
illness  was  characterized  by  most  intense  prostration  and  weakness,  a!id  obstiiuite 
vomiting.  There  was  no  elevation  of  temperature;  the  ])ulse  had  been  rapid,  but 
on  the  morning  of  his  death  it  can.  ■  down  to  forty. 

I  made  the  autoi)sy  on  the  28th  of  March,  1888.  Unfortunately,  the  notes 
which  I  dictated  to  Dr.  Parke  at  the  time  were  mislaid.  The  skin  was  uniformly 
pigmented  and  about  the  color  of  a  mulatto's.  There  was  no  enlargement  of  the 
lymph-glands;  the  heart  and  lungs  were  normal;  no  tuberci.losis;  no  involvement 
of  the  lymph-glands  in  the  abdomen  ;  no  changes  in  the  stom.ach  or  intestine.  The 
suprarenal  glands  alone  were  diseased.  Both  looked  small;  the  right  was  larger 
than  the  left,  and  presented  a  flattened  tuberculous  mass  a'oout  the  size  of  an  almond, 
the  left  a  smaller  mass  in  the  ui)per  part  of  the  gland.  There  was  no  thickening  or 
adhesion  about  the  semilunar  ganglion  in  the  nerves  passing  to  the  glands. 

Case  VI. — Pulmonary  ttiberoulosis;  injury  two  years  ago;  dyspepsia; 
gradual  asthenia;  pigmentation,  deepening  for  nearly  two  years;  treatment 
for  eight  months  with  suprarenal  extract;  rapid  disappearance  of  the 
serious  symptoms  ;  marked  and  persistent  improvement  in  general  condition  ; 
no  cliange  in  the  pigmentation. 

William  H.,  aged  forty-six,  sail-maker,  admitted  to  the  Johns  Hopkins  Hospital 
May  3,  189.'),  complaining  of  cough,  shortness  of  breath,  great  weakness,  and  a 
change  in  the  color  of  his  skin. 

Fatnihj  History.— Hi*  father  died  of  cholera  morbus  and  his  mother  from  the 
effects  of  a  stone  in  the  bladder.  He  had  three  brothers  and  two  sisters,  all  of  whom 
are  dead.  He  does  not  know  of  what  the  brothers  died.  One  sister  died  in  confine- 
ment; the  other  from  poisoning  by  mercury.  He  knows  of  no  tuberculosis  in  his 
family,  and  none  of  his  relatives  have  had  discoloration  of  the  skin. 

Personal  HMori/. -~\Vheu  a  child  he  had  measles,  diphtheria,  chicken-p.ox,  and 
mumps,  and  when  al)out  seventeen  years  of  age,  varioloid.  In  his  sixteenth  year  he 
served  on  board  a  man,  f-war  at  Panama,  where  he  had  a  protracted  fever  of  nearly 
four  months'  duration,  fei'ortly  after  this  he  had  jaundice  for  a  month,  since  when 
he  has  never  had  a  very  healthy  or  natural-looking  color  of  the  skin.  Ten  years  ago 
he  had  two  attacks  of  severe  i»ain  in  the  hypochondriac  and  epigastric  regions,  lasting 
about  five  hours.  He  was  doubled  up  with  the  pain  and  had  to  have  morphine.  The 
attack  was  not  followed  by  either  jaundice  or  chills.  In  vluly,  1893,  the  pati-^nt  was 
run  over  by  a  wagon,  the  wheels  passing  over  his  abdomen  just  below  the  navel.  He 
was  laid  up  for  two  months,  and  suffered  a  great  deal  of  pain  in  the  abdomen.  There 
was  no  paralysis  afterwards,  but  he  has  not  been  very  strong  since.    For  two  years  the 


srx  CASKS 


OF 


:lie  following 
f  the  tionniil 
owed  no  diH- 
,  tliere  wiw  a 
itiuii.    There 

It   nioiitlis; 
Autopsy : 

idclphiii,  Pa. 
iiciit  lie  Imd 
iiid  been  re- 
:estiori,  occa- 
beconie  very 
or.  His  hint 
nd  obstinate 
n  rapid,  but 

Y,  the  notes 
IS  uniformly 
ment  of  the 
involvement 
estine.  The 
it  was  larger 
fan  almond, 
lickening  or 
d». 

(lyspep.sia ; 
;  treatment 
iioe  of  tlie 
I  condition  ; 

ins  Hospital 
ness,  and   a 

er  from  the 
all  of  whom 
i  in  confine- 
ilosis  in  his 

en-p.ox,  and 
2nih  year  he 
er  of  nearly 
,  since  when 
en  years  ago 
ions,  lasting 
piiiiie.  The 
jiiiti'^nt  Wii8 
navel.  He 
Tien.  There 
wo  years  the 


wkin  has  1 


■\l'IHS().\\s   orsKA.SK 


'fen  growing  darker 


I-^t  five  or  six  n^ontl.:,),.  pig..  ,  i.  ;'  '"*  '^'^"'^  "--  no.ieed  tl.at  ni.l.i,,  „.e 
"t  nuervals  tl,n.ug|.,..u  his  life  I  T]  I".''  ';«^''""^'  ""H'h  n.ore  inCns...  11.  ..  ,  ,J 
-"..ting.    Twelve  years  ago  ^       U  /  .t'lt'T  >•  "'  T'"'  "'  '""^^  ''<"^''i'.k  o 

During  the  past  two  years  I.,.  ,,„  l^"";^'    ^  "M.arrhuM.  which  lasted  for  ,  w  ek 

a..<I  l.e  has  the  dvs^^' '^        "'  ""'^  '*'-"'-  "f  breath  o,,   ,,eii  ;:"';'">• 

"Pl-et.te  is  p„or,  but  he  has  l.a.l  „  ,",  "  ,       "^'f''  '""'  ''^  '^^'co,„e  verv  weal       T   ' 
t=on  of  the  heart.  ■'■"'^'-''  ••""!  ""  vomiting.    He  has  had  no  pa,,,!'; 

about  five  leet,  eight  inches       ^^  t:^  ■'^""'"''  -"-ly.onris i  „,„  ^  ,,i^,,, 

a  .nission  wasloPK.;  pulse  i;:    ,2      TV''"''  '""""'^'     '^'■'"l-U..:;^ 
very  apa  hefc.     One's  attention  is  i„  ..      ]    ''i      ,  ^ '"  T^  "''^  •^""'<"".  a-.-l  he  looks 
'""  '>'  "'<■  sl<i..,  Purticularlv  of  the  ,    /  T'T^  '''  ''''  '"'^■"-'  Pi«'..e..ta 

brown  with  irregula,.  patch  s  of  a  d  r  er  't''^'  "•'"^■''  '^  '"'  a  '."i   -r".,    1     , 

are  not  anuMnie.  (,..  the  roof  of  1,  ,,;"■•  ""-'  ''>^  -"'  '"-"^  .".on,  r  le 
on  the  velum  there  is  slight  pig,.  ^1  '"■"  "^  '-'  f'^bes  of  pig,...,,,,.,; 
The  sk.n  of  the  hands  and  wrist:  is  ot  !  .V  V  ""  ""  ''''■^'  ^'''^•'■'^^  -  K"".^ 
.«  .nore  marked  in  the  axiihe  and  he  be  ,7''  ' ir'^n"""'"-  ''''"-'  "'^""-tatio. 
n.pples  and  the  genitals  ,..re  dark  brow  .11..".;  ' ,  "'  ''''"'  "^^'"'^  "''  'be 
be  body  shows  a  marked  bro,„.i„.     T  le    r  "'''"■•     '"''^'  «'^""al  surface  of 

be  shins,  and  there  is  uccentuati,:;;  o  ZCaT  "'  T  ''"'  "'^-"'"i-n  c^ 
1  e  superficial  glands  are  not  enlarge  T ,."  tddi'l ""  '^'t" '"'  ""-'  ^^"^  ^o-- 
rhe  pulse  ,s  regular,  of  niediu,,,  vohune  .  ,V'"'^"'-^"'f-'  a.,d  testes  are  normal, 
tb.ekened.  ^""""^'  '^''"''on  normal,  the  vessel  wall  slightly 

'-'^^r^^^^^S'^^^^^  clavicles  prominent.     The 

Hpace   there  is  a  well-nnirked   friction   r       ^^JT'  "T'  '"•"•«  ''-'"  'be  second 
axillary  regions  and  around  to  the  back    tl,  ""-""Sbout  the  mammary  and 

both  apices  behind  there  are  a  few  fine  n/i  '^?,""'"""  "'«  i"frascapular  area        -V 
"e.ative.     The  sputum  the  ^^Ir^'JX^:^:,.  ?"  '"^  ''"\  '"'  '^^^'^^-^o,^ 
a.n.ng  a  considerable  quantity  of  -^recn  ,'"•'  '''"'"''"'^  """'  ''^'"b.v,  con- 

fou'Hl.  •        "'""'''  "'"«'i'"s,  but  tubercle  bacilli  were  not 

The  apex-beat  of  the  heart  is  in  fwvi    •  . 
The  .sounds  are  everywhere  clear.  ■  ""^'.•■^pace,  just  outside  the  nipple  line. 

The  abdomen  is  somewhat  r.>)n,.t„,i  i 

not  easily  palpable;    no  i^^H  'ZTilr^T  ^'^  ^-''^  "'• 'he  liver  is 
palpable;  neither  kidney  can  be  felt.  ^'"'"''''-     '^''^'  ^P'^^^n  is  not 

There  is  no  enlargement  of  the  thyroid  or  of  tl,„  i        i    .-      , 
lesions  of  the  bones.  ^  ^  ""'  'ymphatic  glands ;  no  nodes  or 

to  35  He  expectorated  a^^S^:  r;;^?::'^^'  -piratio„;.om^ 
which  was  examined  every  other  day  for  tube  1  b  Si  , ,  ^  '"!  ""'^"■"  '"'  ^''"•"'"' 
elastic  tissue  was  foun-".    The  nilienf  I,  J  i  ,       '  ^'"^  ''""'out  result ;  and  no 

and  the  rapidity  of  the  helltS  i  'S.  V:^' T  "^  '•"""'  ^™^'^'"'- 
of  local  disc:i«c  of  the  lung.  ^  "'  *'"  P.-oport.on  to  the  amount 

On  May  16  the  treatment  with  suprarenal  extric  f  . 

suprarenals  were  obtained  it  fl,P  t\,L    T         ,  '^^^""-    Tliirty-si.„  pigs' 


i<      ij 


8 


HIX   CASKS   or    ADDISON  8    DIHKASE. 


I  i; 


I  if. 


!)^ 


^{'! 


wore  aiMi'il,  iiiul  the  whole  nllo\ve<l  to  inuci'riitc  for  thirty-nix  iioiirs  in  a  rcf'rifjonitor. 
TIk;  iiiixtiiri'  was  tiioii  filtered  several  tiiiien  tlir()iiji;li  fiiie-iiieHJied  ^uii/.e.  The  liltrute 
eorisinted  oF  a  reddifth-hriiwn  !*_vru|iy  fluid  of  a  riither  (lisai;reeal)le  odor.  After  filter- 
itif^  tliere  were  tiiirty-eij;lil  driicliiiis  of  the  exlruot,  so  that  one  draelini  corresponded 
to  a  caiisnle.  Tlie  patient  l)e^;aii  with  liuif  a  draclini  of  the  extraet  three  times  a  day. 
The  patient's  hlood-count  when  he  l)e;.'an  the  treatment  was;  red  corpuscles, 
4,5(i4,(Mi(>;  leiieoeytes,  fi(!0<i;  lia'inoj?lol)in,  eighty-five  per  cent. 

On  May  L'lt  tiil)erfle  liaeilii  were  fourul  in  the  expectoration  for  the  first  time. 
Tlie  ciiujrh  and  sliortnessof  breath  had  been  very  mnch  better.  Prior  to  the  treat- 
ment with  the  suprarenal  extract  the  patient  had  );ained  one  pound.  The  note  by 
Dr.  Thayer  on  .May  :.'4,  eifiht  ilays  after  bef^inninn  the  use  of  the  extrai't,  was  :  The 
patient  looks  brijrhter  and  says  he  feels  iietter.  'I'he  pidse,  which  had  ran;;ed  from 
120  to  Ho,  is  now  loo.     He  has  trained  tiiree  pounds  in  weiirht. 

On  June  0  the  amount  of  the  extract  Wiis  increased  so  that  he  took  the  equiva- 
lent of  three  j;lands  daily.  Numerous  careful  blood-counts  were  mode,  and  a  ditfer- 
ential  count  of  the  leucocytes.  There  was  moderate  leiicocytosis ;  there  were  no 
nucleated  corpuscles.  The  number  of  reds  on  .June  (!  was  about  4,000,000  i)er  cubic 
millimetre;  leucocytes,  8000, 

After  May  2o  the  patient's  tomjieraturo  remained  normal. 

Puriiif;  the  week  endinj;  June  1<1  tin'  patient  i;ained  live  and  a  half  pounds, — a 
gain  of  nine  and  a  half  pounds  since  the  use  of  the  extract  was  bejiun.  The  patient 
continued  to  take  the  equivalent  of  three  (glands  daily,  A  note  by  Dr.  Thayer  on 
June  It)  is  as  follows:  Temjierature  has  been  (|uite  normal  for  more  than  a  mouth. 
The  pulse,  which  had  rauf^ed  between  IJO  mid  140  to  the  date  of  bejrinning  the 
extract,  has  gradually  fallen  until  during  the  last  week  the  ranj^e  was  between  84  and 
104.  The  amount  of  sputa  has  diminished  to  less  than  forty  cubic  centimetres  in  the 
day.  The  patient  says  he  feels  much  better;  his  appetite  is  good,  and  he  looks  a 
great  deal  brighter.  The  condition  of  llii'  lung  has  improved,  and  the  friction  murmur 
is  no  longer  heard. 

On  June  28  tubercle  bacilli  were  found.  The  treatment  was  continued  through- 
out July  and  August,  and  in  spite  of  the  hot  weather  he  improved  progressively. 
The  gain  in  weight  was  remarkable.  In  .luly  his  weight  increased  from  one  hundred 
and  ten  and  a  half  to  one  hundred  and  fifteen  pounds.  In  August,  during  the  very 
hot  weather,  he  lost  again  slighly  in  weight. 

He  left  the  hospital  on  .'-September  10.  The  change  in  his  condition  liad  been 
very  remarkable.  When  admitted  he  could  scarcely  walk  to  the  bed,  and  was  pro- 
foundly asthenic  and  emaciated.  The  general  appearance  had  improved  wonderfully  ; 
he  was  bright  and  active,  and  said  he  felt  vigorfms.  His  weight  on  discharge  was 
one  hundred  and  eighteen  pounds,  a  gain  of  nineteen  pounds.  The  pigmentation 
was  unaltered. 

yince  Jiis  discharge  he  lias  been  at  work,  and  has  reported  at  the  hospital  occa- 
sionally. He  felt  so  well  that  throughout  che  latter  part  of  November  and  Decem- 
ber lie  renuiined  without  any  of  the  suprarenal  extract,  and  he  lost  three  i)ounds  in 
weight  in  that  time.     His  condition  to-day — January  15,  181)(3 — is  as  follows: 

The  color  is  good.  To  me  his  face  looks  a  little  less  pigmented,  but  Dr.  Thayer, 
who  had  the  i>atient  in  charge  during  the  summer,  wliile  he  was  in  ifie  ward,  does  not 
think  that  there  is  any  material  change  in  the  face,  but  thinks  the  discoloration  is  less 
intense  on  the  trunk.  It  is  still  of  a  very  advanced  grade,  such  as  is  seen  only  in  the 
most  typical  cases  of  the  disease.  The  small  patches  of  pigmentation  on  the  pal  3 
have  disappeared.  The  local  comlition  in  the  lung  has  cleared,  and  there  are  now 
only  a  few  rales  to  be  heard  occasionally  on  coughing.  The  friction  is  still  audible 
just  outside  the  right  nipple.  The  change  in  the  patient's  general  vigor  is  remark- 
able. He  walks  briskly,  is  active,  energetic,  in  very  good  spirits,  and  siiys  that  he  is 
as  well  as  he  ever  was  in  his  life. 


I  reCriKeriitor. 
,  The  liltriite 
Alter  fUter- 
correspotided 
!  times  a  iliiy. 
il  eorpuMcles, 

he  flr.Ht  time, 
to  tile  treiil- 
Tiio  note  by 

L't,  wiis  :  The 
riin^^eil  i'roiii 

Ic  tlie  e(|iiivii- 
iind  a  diifer- 
lere  were  no 
(»0  per  cubic 


t"  pouiidx, — a 
Tlie  patient 
r.  Tiiayer  on 
)an  a  month, 
?ginninf?  the 
twecn  84  and 
metres  in  the 
,d  he  h)oks  a 
tion  murmur 

led  tlirough- 
mgressively. 
one  iiundred 
•ing  tiie  very 

;)n  liiid  been 
md  was  pro- 
iVonderfully ; 
iscliarge  was 
)igmentation 


ospital  occa- 
and  Decem- 
ee  pounds  in 
ows : 

Dr,  Thayer, 
ard,  does  not 
ration  is  less 
n  only  in  the 
n  the  pal  3 
lere  are  now 
still  audible 
r  is  reniark- 
ys  that  he  is 


t  ?' 


International 
Medical 
Magazine. 


AN 
ILLUSTRATED    MONTHLY 

OCVOTCO   TO 

MEDICAL    AND    aUROICAL 

SCIENCE. 


EDITED.    UNDER   THE   SUPERVISION   OF 


'    i 


;f 


■\  i    I 


JOHN  A8HHURST,  JR..  M.D.,  AND  JA8.  T.  WHITTAKEK,  M.D..  LL.D., 


BY 


HENRY  W.  CATTELL,  A.M.,  M.D. 


THE  development  of  medical  science  i.s  proceeding  at  such  a 
rapid  rate  that  a  medical  journal  is  an  absolute  necessity  to 
every  practising  physician.  The  Intkrnationai.  Mkdicai 
Magazinb  supplies  this  need  by  giving,  as  it  does,  authorit, 
tive  expression  to  the  results  of  the  experience  and  investiga- 
tions of  the  foremost  physicians,  surgeons,  and  lecturers  of  the  leading 
medical  .schools  of  the  United  Stateo  and  Canada,  together  with  those  oi 
the  great  medical  centres  abroad,  such  as  London,  Paris,  Berlin,  and 
Vienna. 

Th6  contents  of  each  number  embrace  Original  Contributions  and 
Clinical  Lectures  by  leading  practitioners,  whose  labors  are  exercising  a 
directive,  stimulating,  and  con.servative  influence  on  tlie  healing  art. 

In  addition  to  these  departments  and  with  a  view  to  securing  ex- 
haustiveness,  thoroughness,  and  reliability,  .specialists,  tried  in  the  school 
of  experience  and  tested  by  their  success  in  their  specialty,  have  beta 
placed  in  charge  of  separate  departments  embracing  the  following  subjects 
Medicine.  Therapeutics,  Neurology,  Pediatrics,  vSurgery,  Genito-Urinary 
Surgery,  Orthopaedics,  Obstetrics  and  Gynaecology,  Ophthalmology  and 
Otology  Laryngology  and  Rhinology,  Dermatology,  Hygiene  and  Bac- 
tenologi ,  Pathology,  and  Climatology.  To  this  must  be  added  translations 
of  what  is  best  from  the  medical  literature  of  Italy,  Spain,  and  Portugal. 

The  department  of  Forensic  Medicine,  dealing  with  mer*'  '>  !c  1 
questions,  and  the  legal  duties  and  respo  bilities  arising  out  rtt,  -.  < 
incidental  to,  the  relation  of  physician  and  patient,  as  ascertr  -  1  n  ' 
defined  by  courts  of  last  resort,  has  proved  an  interesting  and  ^^aiuable 
feature  of  the  Magazine,  and  called  forth  many  expressions  of  apprecia- 
tion and  approval  from  its  readers. 

The  department  of  Book  Reviews  furnishes  a  brief  critical  anal\  sis 
of  all  the  n.  -t:  important  medical  books  and  periodicals  as  soon  as  they 
are  publisnec« 

The  K'gi<  icci'-'.':,  therefore,  the  medium  by  which  all  tint 

is  settled  as  as>  ,  i  o'-  rj  department  of  medical  and  surgical  science 
throughout  nt.  •  v  'l-ai  world,  ''•  placed  within  the  means  of  every 
practitioner. 

INTERNATIONAL  MEDICAL.  MAGAZINE  COMPANY, 

PUBLISHERS. 

716  Filbert  Street,  Philadelphia,  U.  S.  A. 


SAMPLE  COPY 

atsm   un 
APPLICATION. 


:0    MONTHLY 

TCO   TO 

HO    aUROICAL 

CNCE. 


M.D.,  LL.D., 


ig  at  such  a 
;  necessity  to 
Ah  Medicai. 
€s,  authorit.i- 
tid  investiga- 
f  the  leadiiii.; 
with  those  (il 
,  Berlin,  antl 

ibutions  and 
:  exercising  a 
ling  art. 
securing  ex- 
in  the  school 
Y,  have  bei.n 
'ing  subjects : 
inito-Urinarv 
ilmology  and 
;ne  and  Bac- 
i  translations 
nd  Portugal, 
mec^v.  'c  ; 
out  r-t, 
ertr  n  ' 

and  »/Uiuable 
i  of  apprecia- 

tical  analjsis 
soon  as  tluy 

lich  all  that 
gical  science 
ns  of  every 

lOMPANY, 


ADDISON-S  DISEASE 


BV 


WILLIAM  OSLER,  M.D 


iversity  0/  Baliimore 


An  a.J,ln>s«  ,!eliverej  bofor,.  the  c!as„w  of  il„.  \I„  i, .    r> 

'in  laiiiKiiy  L'l,  1890, 


go  01   I'liila.lril 


^"■'^"""'^    ™m   lHH.\l,„„,M.  „„.,,,,„- 


phia,  U.  S.  A. 


i\ 


1 1 


f^ 


The  glan 

are  divided 

tliein,  as  the 

elaborate  n 

are  poured 

serve  some 

meiititious. 

cretion,  one 

and  the  othe 

directly  or  t 

phatics,  and 

Icretion.     Tc 

livliich  forms 

,ncrens,  wl 

ItivetJiiid  anc: 

markable  gl} 

;  tliird  groi 

pleen,  thyrc 

Jprarenal   hoc 

tritices  of  dis 

Jess  glands." 

lemal  secreti 

pe  blood  anc 

;  glands,  a 

ive  most  in; 

|(5S  of  our  ki 

pse  glands 

Let  n 

le  functions  ( 

pnncrin  whi 

1  In  the  first 

'  in  region 

liany  of  the  c 

lairmcnt  in  f 

The  HI 

|r3iigely  malf 

:  or  feebli 

•  An  addri 


ADDISON'S 


I'V  WILLIAM 0 

t'rofesso,-  of  A;=cii,:i„e  ,„  ,he  j„|,„,  „ 


The  .g^lands  of  the  body,  you  are  auar. 
are  divided  into  different  classes;  cer  •  n  oi 
t)em,  as  the  sahvary  glands  and  tlie  kidneys 
elaborate  materials  from  the  blood,  wiiich 
are  poured  out  externally  and  which  either 
serve  some  useful  purpose  or  are  exc  e- 
.entitious.  Other  glands  have  a  doulle    e- 
cre.on,  one  of  which  is  discharged  bv  a  duct 
ar.d  t  e  other  is  passed  into  the%lo    I  eit t 
rectly  or  throughthe  medium  of  the     •  m 
phat.cs,  and  hence  is  termed  an  mternal    e- 
>t.on      To   this  group   belong  the  1  ver 

be  cT  which'  ''^  r'  ^'^•'^°^-"'  '-'the  ' 
ancreas,  which  secretes  a  powerful  diges- 

ive  flind  and  an  internal  secretion  with  ."i-e-  : 

babble  glycolytic  function.    Then  there  is  i 

tlnrd  group  o    glands,   comprising   Ue 

.leen,  thyroid,  thymus,  pituitaiv,  and      ! 

-rarenai  bodies,  which  have  no  ducts  or 

e.-s  glands.  _  These  bodies  elaborate  an  in- 

IM^  Jr'"?"  ;-''V''?  '^'^  P^'"-^^!  '^^ck  into  I 
I  e  blood  and  which,  in  the  case  of  some  of 

lieglands.at  any  rate,  has  been  shown  to 

tave  most  important  functions.    The  nro"- 

r     ?"'\'^"°^^I«'ge  of  the  phvsiologv  of 

lese  glands  has  been  very  rapid  of  late 

b    !■''  '"?  f''\  '^^"  yo"r  attention  to 
le  functions  of  the  thyroid  gland  and  to  the 

te  fi'" '",''  "''•^'  ':"^'^  '^^"^  determined. 
In  the  first  place,  It  has  long  been  known 

Ian}  of  the  children  present  a  peculiar  im- 
pairment in  physical  and   mental  dei 
■'^y^'i^'^t-';'  '^'"own  as  cretin 
•  com 


|ti 

iir 
i 
o> 

:'  n 

n 

n 

il 


ptic  or  feeble-minded.  The 


iplctcl 
y  are  fouTid  pat 


•  An  .ddres,  delivered  before  the  classes  of  the  Medico-i 


Scluff  had  demo, 
series  of  change,, 
tion  of  the  thn-o 
scrvations  were  c 
many   observers 
whose   experime, 
iiiunkeys.    it  u;i- 
"ivariably  f,,]io^,. 
^■'■'"d,  and  in  nu,, 
ticed  very  simila 
"'^■"-    if.  on  the  . 
an-  thyroid  gku,; 
not  occur,  or  evei 
gland  were  left   . 
tile  thyroid  were 
nial  operated  un,j| 
'"^■"tal    studies   ( 
the  prune  functio, 
roid  lor  the  norm 
il'.en  came  tiie' 
duction  which  ha 
striking  therapon 
eni  times.    I„asn 
oi  symptoms  folk 
aiinnal  did  not  oc 
animal  were  tran,' 

ural  suggestion  w 
ray— a  pupil  of  I- 
procedure  in  cas. 
plantation   was  a 
found  that  feedinr 
advantageous  or"" 
nsed  subcutaneou 
Alurray's  shrewd 
one  of  the  most  i 
"Story  of  therap. 
»een  before  the  p 
long  enough  in  w 
nicnt,  and  it  may 
t'lyroid  feeding  in 
early  cretinism  ai 
tical  medicine.     J 
tration.    A  lady  c 
months  ago,  wht 
changing  gradual! 
J^.v- ^  She  had  bee 
Habby,  and  the  ^ 
face  puffy,  and  tit. 
were  great  cushi, 
cous  tissue  about 
•"'rv.  ami  there  wa^ 
Pccia.     She  had  - 
bright,  active,  inte 
taking  charge  of  a 
listless  apathetic  i 
was  to  be  let  alo, 
advanced  case  of 
to  walk,  and  pres( 


li 


ADDISON'S  DISEASE. 


By  WILLIAM  OSLKR,  M.J)., 

Professor  of  Medicine  i„  ,he  Johns  Hupk.ns  Universi.y  of  a.l.i.norc. 


[The  ^.ands  of    he  body,  you  are  aware, 
|e  divided  into  different  classes;  certain  of 
pn,  as  tile  salivary  glands  and  the  kidneys 
bborate  materials  from  the  blood,  which 
le  poured  out  externally  and  which  either 
Irve  some   useful   purpose  or  are   excre- 
lentitious.  Other  glands  have  a  double  se- 
ttion,  one  of  which  is  discharged  by  a  duct 
Id  the  other  is  passed  into  the  blood  either 
Irectiy  or  through  the  medium  of  the  lym- 
latics,  and  hence  is  termed  an  internal  se- 
pon      To  this  group  belong  the   liver, 
lich  forms  both  bile  and  glycogen,  and  the 
ticreas,  which  secretes  a  powerful  diges- 
le  fluid  and  an  internal  secretion  with  a  re- 
Irkable  glycolytic  function.    Then  there  is 
■third  group  of  glands,   comprising  the 
■een,  thyroid,  thymus,  pituitary,  and  su- 
Irenal  bodies,  which  have  no  ducts  or 
'Hces  of  discharge;  hence,  the  term  "duct- 
s glands.'    These  bodies  elaborate  an  in- 
to secretion  which  is  poured  back  into 
blood  and  which,  in  the  case  of  some  of 
glands,_  at  any  rate,  has  been  shown  to 
le  most  important  functions.    The  prog-  j 
Is  of  our  knowledge  of  the  phvsiology  of 
|se  glands  has  been  verv  rapid  of  late  I 
rs.    Let  me  f^rst  call  vour  attention  to  j 
» functions  of  the  thyroid  gland  and  to  the 
inner  m  which  they  have  been  determined 
in  the  first  place,  it  has  long  been  known 
I 'n  regions  in  which  goitre  is  endemic 
fly  of  the  children  present  a  peculiar  im- 
fnient  in  phvsiral  and  mental  dcvclop- 
ft.    The  subjects,  known  as  cretins,  are 
,'igdy  malformed,  and  either  completelv 
pc  or  feeble-minded.  Thev  are  fouTid  par- 


ticularly in  certain  European  countries,  and 
m  some  ot  tiie  Cantons  (,t  Switzerland  thev 
occur  by  hundreds.  It  lias  long  been  recog- 
nized that  the  condition  is  in  some  way  con- 
nected with  disease  or  atrophy  of  the  thy- 
roid gland.  While  the  allectfon  is  endemic 
n  certain  regions,  it  also  occurs  sporadical- 
y,  and  cretins  are  occasionally  met  with  in 
tins  country. 

Si/\v!n^  second  place,  tl,e  observations  of 
Sir  Wlliam  Gull  and  Dr.  Ord  showed  that 
m  adults  a  remarkable  physical  and  mental 
change  was  liable  to  supervene  in  certain 
forms  of  disease  of  the  thyroid  gland  The 
subjects  of  the  affection  presented  a  grea? 

:  thickening  ot  the  subcutaneous  tissues 
marked  change  in  the  nutrition  of  the  skin' 

I  and  a  gradual  impairment  of  the  brain-func- 
tion leading  ultimately  to  dementia  So 
similar  was  this  conditin,,  to  that  of  the  ere- 


»  An  addresi 


itin  that  Sir  William  G„1I  called  it  the  "cre- 
:  tinoid  state,"  and  Dr.  Ord  .gave  it  the  name 
,  of  myxedema,  owing  t,.  the  large  amount 
I  of  mucoid  material  in  the  subcutaneous  tis- 
sues. 

A  further  step  was  the  discovery  bv  sur- 
geons, particularly  by  Kocher  and  bv  Rev- 
crdin.  that  total  extirpation  of  the  thvroid 
as  IS  so  often  practiced  in  goitre,  was  follow- 
I  ed  in  a  certain  number  nf  cases  by  a  condi- 
tion identical  with  that  of  mvxedema  The 
patients  grew  listless  and  apathetic  and  the 
cutaneous  tissues  underwent  the  same  re- 
markable change  alroadv  referred  to 

These  were  the  clinical  contributions  to 
the  question.  Then  the  experimental  physi- 
ologists added  their  all-important  studies 


delivered  before  ,he  classes  of  ,he  Medico-Chirurgical  College  of  Philadelphia  on  hnu:.ry^s^,~ 


Ml^l^lOUlN  S    IJlSJtAbi'. 


i 


Scliiff  IkuI  (li'inoulratrd  that  a  remarkable 
scries  ul  I'liau.Ljes  tollnwotl  complete  extirpa- 
ticm  ul  the  tiivroid  in  animals,  and  his  ob- 
servations were  conlirnied  and  extended  by 
many  oi)scrvers,  particularly  by  liorsley, 
whose  experiments  were  condncted  npon 
HKjnkeys.  It  was  shown  that  these  changes 
invariably  followed  total  extirpation  of  the 
gland,  and  in  monkeys  a  contlitimi  was  no- 
ticeil  very  similai  indeed  to  myxedema  in 
men.  if,  on  the  other  hand,  a  snpernnnier- 
ary  thyroid  gland  existed,  the  cliange  did 
not  occnr,  or  even  if  a  small  fragment  of  the 
gland  were  left,  or  if,  indeed,  a  portion  of 
tile  thyroid  were  transiilanted  into  the  ani- 
mal oi)eratcd  npon.  The  clinical  and  experi- 
mental slnilies  demonstrated  conclnsively 
the  prime  fnnctional  importance  of  the  thy- 
roid for  the  normal  metabolism  of  the  body. 
Then  c.une  the  all-important  practical  de- 
dnction  which  has  proved  one  of  the  most 
striking  therapentical  discoveries  of  mod- 
ern times.  Inasinnch  as  the  peculiar  train 
of  svmjiionis  following  thyroiilcctomy  in  an 
animal  (hd  m^t  occnr  if  a  gland  from  another 
animal  were  transplanted,  it  was  a  very. nat- 
ural suggestion  which  occurred  to  Dr.  Mur- 
ray— a  pupil  of  llorsley'.s — to  try  the  same 
jirocedin-e  in  cases  of  myxedema.  Trans- 
plaiuation  was  at  first  used;  then  it  was 
found  that  feeding  by  the  mouth  was  equally 
advantageous  or  the  extract  of  the  gland 
used  sulicntaneoiisly.  The  consequences  of 
Murray's  shrewd  suggestion  have  opened 
one  of  the  most  interesting  chapters  in  the 
history  of  ther.ipentics.  The  treatment  has 
been  before  the  profession  now  for  a  period 
long  enough  in  which  to  form  a  clear  judg- 
ment, and  it  may  be  said  that  the  results  of 
thyrt)id  feetling  in  myxedema  and  in  cases  of 
early  cretinism  are  without  parallel  in  prac- 
tical medicine.  Let  ine  give  you  an  illus- 
tration. A  lady  came  under  my  care  some 
months  ago,  who  for  six  years  had  been 
changing  gradually,  both  mentally  and  bod- 
ilv.  She  had  l-,ecoinc  heavy,  bloated,  and 
flabby,  and  tlu-  skin  exceedingly  dry,  the 
face  jMiffy,  and  the  eyelids  baggy,  and  there 
were  great  cushions  of  swollen,  subcutan- 
eous tissue  about  the  neck.  The  hair  >• 
dry,  and  there  w;is  a  condition  r.t  patchy  alo- 
pecia. She  bad  changed  mentallv  from  a 
bright,  active,  intelligent  woman,  capable  of 
taking  charge  of  a  large  household,  to  a  dull, 
listless  aiiathetic  creature  whose  only  wish 
was  to  be  let  ;il<.iie.  Tn  short,  she  was  an 
advanced  case  of  myxedema,  scarcely  able 
to  walk,  ;in(l  presenting  in  many  respects  a 


pitiful   caricature  of  t'.ie  human   fonn  al 
face.    Within  three  months  under  the  iiuj 
the  thyroid  extract  she  had  lost  all  tid- 
ed a])pearancc;  phy5,ically  she  had  !).iiji| 
active  and  energe'^^'c,  and  mentally  :-:.f  loj 
an  interest  in  everyt  '."ng.    She  rerunic 
her  Imiic,  resumed  her  domestic  r-.w  <:^  y. 
has  been  practically  rescued  from  a  c  iij 
tion  of  hopeless  fatuity,  and  she  is  apiiii 
happy   and   intelligent  member  of  ^.r] 
This   ,s  not  an   isolated   instancy   iu: 
cases  are  now  numbered  by  scores;  l.i.  ihj 
the  infantile  and  adult  myxedema  '.his 
markable  change  has  been  effecte  1.    TJ 
is  a  brilliant  triumph,  too,  for  experiiiuMi] 
medicine. 

The  facts  which  I  have  nientiom;!  :ii| 
cate  clearly  that  the  thyroid  gland  seep, 
some  important  substance  whicli,  'lo-ii 
back  into  the  circulation,  is  of  vital  impi 
in  maintaining  the  metabolism  of  the  br[ 
and  of  the  subcutaneous  tissues. 

How  stands  the  case  now  of  .\dfli?i)l 
disease?    Eleven  years  ago  in  Pepper's  "Si 
tern  of  jMedicine"  I  wrote  as  folke     ■ 
relation  of  affections  of  the  thyroid  .^land 
myxedema  and  cretinism  and   the  expl 
mental  production  of  these  conditions  bvf 
removal  of  the  thyroid  have  widened 
view    of    the    importance    of   the    diictll 
glands.    In  both  there  are  distinct  histoll 
ical  changes  in  the  tissues — in  one,  anj 
crease  in  the  mucin ;  in  the  other,  an  incre| 
in  the  jiigment — and  in  both  marked  nd 
ous  phenomena;  mental  dullness,  a  pro^; 
sive  dementia  in  myxedema,  a  profound  I 
thenia  in  Addison's  disease.     We  re.^jarj 
the  thyroid  as  unimportant  to  life  until  I 
experience  of  surgeons  and  extiipationj 
monkeys  by  Horsley  demonstrated  thatal 
lition  of  its  function  was  followed  by  a  si 
ous  traif  of  symptoms;  and  perhaps  the  I 
perimental   removal   of  the  suprarcnalsj 
monkey.s — so  much  more  closely  allieif 
man  than  the  animals  hitherto  expcrinieij 
upon — may    demonstrate    that    these 
bodies  are  also  not  without  their  infliiej 
upon  health." 

We  may  divide  the  steps  in  our  Rnq 
c(\s:e.  as  we  did  in  the  thyroid,  into  the( 
ical.  experimental,  and  therapeutic.  .\\ 
son  in  7854  described  the  disease  very  f| 
oughly  and  recognized  the  three  iniporl 
svmptoms — namely,  gradual  det  pcninft 
the  pigmentation  of  the  skin;  protMini'l 


th 


en  I  a 


both  nmscular  and  mental,  and 


tro-intestinal    disturbances.      Anatnniicj 
Addison  found  that  these  clinrcal  syniptl 


i: 


i\uuisyjis  s  uiSJLASfc. 


ntrated  that  a  remarkable 

followed  complete  extirpa- 

id  in  animals,  and  his  ob- 

onfinned  and  exteiuled  by 

particularly   by    llorsley, 

ats   were   conducted   upon 

i  shown  that  these  changes 

ed  total  extirpation  of  the 

nkeys  a  condition  was  no- 

r  indeed  to  myxedema  in 

other  hand,  a  supernumer- 

d  existed,  the  change  ilid 

1  if  a  sn'all  fragment  of  the 

or  if,  indeed,  a  portion  of 

transplanted  into  the  ani- 

1.    The  clinical  and  experi- 

lenionstratcd   conclusively 

nal  importance  of  the  thy- 

al  metabolism  of  the  body. 

all-important  practical  de- 

s  proved  one  of  the  most 

tical  discoveries  of  mod- 

luch  as  the  peculiar  train 

iwing  thyroidectomy  in  an 

:ur  if  a  gland  from  another 

-.planted,  it  was  a  very.nat- 

hich  occurred  to  Dr.  Mur- 

lorsley's— to  try  the  same 

;s  of  mvxedema.     Trans- 

t  first   used;  then   it  was 

•  by  the  mouth  was  equally 

the  extract  of  the  gland 

sly.    The  consequences  of 

suggestion  have   opened 

nteresting  chapters  in  the 

'Utics.    The  treatment  has 

rofession  now  for  a  period 

hich  to  form  a  clear  judg- 

be  said  that  the  results  of 

myxedema  and  in  cases  of 

•e  without  parallel  in  prac- 

.et  me  give  you  an  illus- 

ame  under  my  care  some 

)  for  six  years  had  been 

y,  both  mentally  and  bod- 

■omc  heavy,  bloated,  and 

kin  exceedingly  dry,  the 

I  eyelids  baggy,  and  there 

)ns'  of  swollen,  subcutan- 

the  neck.    The  hair  ^' 

a  condition  r.f  i\'itchy  alo- 

Mianged  mentallv  from  a 

lligent  woman,  capable  of 

large  household,  to  a  dull, 

•reatnre  whose  only  wish 

le.     In  short,  she  was  an 

myxedema,  scarcely  able 

■nting  in  many  respects  a 


pitiful  caricature  of  tlie  human   fonn  rind 
face.    Within  three  moi>;hs  under  tlu  u>^: 
the  thyroid  extract  slie  had  lost  all  lur  l);.,:,t| 
ed  appearance;  phys.ically  she  had  luoiir,. 
active  ami  energetic,  and  mentally  ,>;.e  ioqiJ 
an  interest  in  everyt  I'ng.     She  rerunie: 
her  Iniiic,  resumed  her  domestic  r.n'  (_ 
has  been  practically  rei-cued  from  a  cjirj 
tion  of  hopeless  fatuity,  and  she  is  ;ii^ain 
happy   and   intelligetit  member  of  s.v. 
This   .s  not  an   isol.^ttd   instancy   i.  i*. 
cases  are  now  numbered  by  scores;  !■  i.i 
the  infantile  and  adult  myxedema  'lib 
markable  change  has  been  effecte  I.    T 
is  a  brilliant  triumpli,  too,  for  experiMn.u 
medicine. 

The  facts  which  1  have  mention'  i  ;:, 
cate  clearly  that  the  thyroid  gland  sucr, 
some   important   substance   which,  iiou-el 
back  into  the  circulation,  is  of  vital  impo 
in  maintaining  the  metabolism  of  t!,i>  brai 
and  of  the  subcutaneous  tissues. 

How  stands  the  case  now  of  Addison 

disease?    Eleven  years  ago  in  Pepper's  "Sy 

tern  of  Medicine"  I  wrote  as  follows:   "T! 

relation  of  affections  of  the  thyroid  glanr 

mvxedema  and   cretinism  and   the  exper 

mental  production  of  these  conditions  byti 

removal  of  the  thyroid  have  widened  o 

view    of    the    importance    of    the    ductle 

glands.    In  both  there  are  distmct  liistnk, 

ical  changes  in  the  tissues — in  one,  an  i 

crease  in  the  mucin ;  in  the  other,  an  increa 

in  the  pigment — and  in  both  marked  ne 

ous  phenomena;  mental  dullness,  a  pM;;ri 

sive  dementia  in  myxedema,  a  profound; 

thcnia  in  Addison's  disease.    We  re.ijard 

the  thyroid  as  unimportant  to  life  until  i 

experience  of  surgeons  and  extirpatinn 

monkevs  by  Horsley  demonstrated  tliatal 

lition  of  its  function  was  followed  by  a  >t| 

ous  train  of  sv:nptoms;  and  perhaps  tlie 

perimental   removal   of  the  suprarcnab 

monkevs — so  much  more  closely  allie'' 

man  than  the  animals  hitherto  experiniei 

i,pnn — may    demonstrate    that    th-^sc  i 

bodies  arc"  also  not  without  their  influe 

upon  health." 

We  may  divide  the  steps  in  our  \m\ 
edge,  as  we  did  in  the  thyroid,  into  tliecii 
ical,  experimental,  and  therapeutic.  .V| 
son  in  1S54  described  the  disease  vervts 
oughlv  and  recognized  the  three  iniivnii 
svmptoms — namely,  gradual  deepenin?; 
the  pigmontation  of  the  sl-rin:  pm' 


\i-\m' 


thcnia, 


'both  iiniscular  and  mental,  av 


tro-intestinal    disturbances. 


.\naff 


Addison  found  that  these  clinrcal 


;vini 


tlic  human  foim  niid 

J  lUli  ni:!ii.  an  livi   Ij.'l^fj 

cally  she  had  liccoir, 


...^  .„^_    were  associati-d  uitli  rhn  ~  ^~~ 

ot'lhs  uikIlt  th.  u>,M    '•'■"aJ  Ijoch'cs,  usuallv  n  r//^'"""  '"  *'"^  ^"P^a-, 
■  had  lost  aU  luT  b:r,a«    tmn,  which  was  subscni    mN"'''f""'  ^''^■'"a^ 

■    tuberculous.    Wliil    t     '    'I'L"'"^^"  ^"  I^- 

tc.-ation,  in  other  nmi  n  "-  ^""""(^n  al- 

f;la^dshash.;^n..,;:^':!"^^^^trophyof  tlK. 


V  CllI^         .-ill^       ..«V4        I'Vk^.J] 

Mud  nientaily  s'.i,'  I'j.j 
'."r.y.  She  rerunie;! '. 
^r  doimstic  c.n' 


'11  j| 

un 

■i'.'t\ 


rescued  from  a  c 
ity,  and  she  is  ag; 
It  member  of  s., 
V.i.d  instancy  l):i.  , 
;red  Ijy  scores;  1'  n'n  ,| 
.lit  myxedema  '.bis  ri 
s  been  effecte  1.  Tl; 
,  too,  for  cxperinKMir 

have  mention''  1 
thyroid  gland  -.. 
)stance   which,  n. 
ition,  is  of  vital  im[>jr 
letabolism  of  tliu  bra 
ous  tissues. 
:asc  now  of  A(l(li?i:i| 
rs  ago  in  Pepper's  "S,i 
vrote  as  follow?:   "tii 
of  the  thyroid  rjKiii 
:inism  and   the  expd 

these  conditions  byt'i 
•oid  have  widened  n 
•tance    of   the    diictu 
re  are  distmct  histnk 
tissues — in  one,  an 
in  the  other,  an  iiiireal 
1  in  both  marked  ner 
ntal  dullness,  a  pr^X'' 
xodcma,  a  profouii' 

disease.     We  regarcl 
portant  to  life  until 
'ons  and  extiri'.atii^:; 
'  demonstrated  tliatal) 

was  followed  by  a  jfj 
ns;  and  perhaps  tliei 

of  the   suprarena!? 

more  closely  alliei 
Is  hitherto  expcrime".j 
strate    that   th-^^e  lit 

without  their  infld 

:he  steps  in  our  kiij 
he  thvroid,  into  theal 
and  therapeutic.  .\'t 
^d  the  disease  verv;:j 
izcd  the  three  inqv. 
,  gradual  dcepcninjl 
f  the  skin:  profuitnil 
lar  and  mental,  aiifl! 
rbances.  Anatniiiicf 
:  these  clinrcal  sviii] 


-■''•'^  again 


cancer,  and  in  a  h-w  cV"'  "■'  '  >.    -■ 

n-t  been  .nuC  a  ded  to  o'"'  ,  '"''^■'■^'  ''■''■^ 
anatonn-cai  know  "  'of  A,  r'"":''  '''"'' 
ea.se.    You  will  ihuuCc  urw'""  '    '''■^- 

R.Mleston's  Goulsto  i'm  r  ..V'"^"'^''--'  '■> 
Ruval  College  of  P        -;  ^^'"^"'•^'s    at    the 

tl.c  Lancet  In^  ll^ZT'v'^f'r'''''^  ^" 
Vol.  I.  of  last  year  '''^""'   -'^ii>-nal, 

Iv  by  A  ldiso,^'s  n°  :  .'  ^^"^'''-^^^^'1  direct- 
Slands  were  necefsan  'to'^"-'^'"''^;^'  '^'''  ^''^^ 

the  pigment.  I  must  ^Kr  iuo?'f""  °' 
Lectures  for  full  detailsof  ?1  o     ,  ^"""^^-^to"  « 

pcriments.     Recenlv   S  l      f   '  ''"''"'^"^  '-'-^- 

Lve  found  tl;a^an^x''f^rM'"^''''^^^^ 
tiie  mcdullaiy  portion  of  .  ''""'  ""'^'" 
gland  contains  a^i  or°"  n^  n  '  •^"P"'"^"'''! 
traordinarv  power  ?h  ^^T^'^'  °^>'^- 
"pon  the  muscular  fiir  s  of  tie  h ''''.''""^' 
tl>e  peripheral  arteries  anflnl  '''"  ''""' 
vokintarv  muscles     Tho  '"  "P°"  ^he 

the  balance  of  evidence  ;«  1        ,    "   ".  ^'^''^ 
oftbe  view  that  the  adrenn"^"^'--'  '"  ^*■^^'"'• 

Liands  which  <SmS.ui^"  ^  ,":;;.;:'"^^'-^='' 

The  third  step,  which  in  the  case  of  tb. 
flvroKl  has  so  brilliantlv  clinched  and  In 

pMi  ixcn   taken  m  connect  on   witli  Arlrli 

ra  t  of  the  gland  to  patients.    The  disc-i^, 
I'so  rare  that  onlv  a  few  ri«n^  i,  ' 

h '-««!.  .-..Ki  ,„:  tSmf ,"  J  ?:  11 

h  any  nirans  .issiirccl.     T  li.ivc  ]ZllZ  I, 


"bich  has  improved 
•;.;  nianner.  The  folloi 
(iliis  history :    Wm   H 


ui  a  vcrv  re 


niarka 


ownu 


IS  an  aijstrac 
aged  46,  ,snil-mak 


-asrulmitted  to  the  Johns  II^pkinsTr 


On  S 


the  ch 


cpteniljcr 
a"ge  in  his 


way  remarkable  J 
pounds,  was  bright 
t>ve  and  vigoroiTs. 
whatever  in  the  pirr, 
.  \  showed  this  pat 
e'ff'it  montbs  after 
treatment.  He  co,i 
He  has  no  longer  a 
ji's  busuiess,  and  sa- 

there  i,s  no  essentia 
tation. 

.^'nie  alone  will  1 

tarn  by  this  method 
results  such  as  we  1 
the  use  of  the  thvrc 
all  probable  that  the 
'y^^ood.    In  the  firs 
adrenals  associated 
IS  often  only  a  part  c 
tn  advanced  cases  1 
extract  i.s  not  likel'v 
associated  with  mal 


pal,  May  3,  1895 


stiff  e 


ring  from  cougb 


;::-™Si'ii  St--"- 

anatomical    kno^^U^^yZlt'''"^  'T^ 

riie  cxi)crinicntal  steps  in  our  knou-k.<lcr. 

j;^by„o„.eanssoa.,ipleteori;":t    £ 
toi->  a.  in  the  case  of  tlie  thvroid      lirown 

?rAdSo:V'°'^"^^^^'"'^''^'^-'^i-"- 

^anLl;;;^^:;LSi;rtoi;ie'^;!?,;i;?-'-^ 

influenced  in  some  vvav  t    .    T  i  *'"--^' 

the  pigment.  I  mt^t  o?i  o  ,  to  Rolll"."  ^' 
Lectures  for  full  details  of  l>e  s  Lccu  ntTx' 
pernnents.  Recently  Schaefer  and  O  iver" 
lave  found  that  an  extract  nreinrerl  fr^f.^ 
he  medullary  portion  of  t'he'Crarc  " 
gland  contams  an  organic  princi  e  o  "k 
traordmary  pouer  which  'acts  esnccialh^ 
upon  the  nmscular  fibres  of  tie  heart  a    I 

C  P^'^'"'^^"'  ""''''''''  ^'"I  '-ilso  noon  t  e 
Ivoluntary  muscles.     Thev  were  ,ir     .iVi     . 

p>t^ct^^;;j^;sSco!i^,e??-;i 

I  present  the  most  that  we  can  s      is' 1 1  a 
I  e  balance  of  evidence  is  strongly  in  favor 

*  nds  which  contribute  an  important  inter- 
tl  secretion  the  nature  of  which  is  as  yet 
determined,  but  which  probably  has  ^an 

KfXsl""'"'?  °"  the  normal  metabo- 
m  ot  the  skin  and  muscles 

(The  third  step,  which  in  the  case  of  the 

|yroid  has  so  brilliantiv  clinched  and  Inr- 

rbet^H,'^""'^'''^'  '"'^  experimental'd'  , 
Is  been   taken  m  connection   with  Addi- 

Ic  niT"  '7  ''r  ''^^'■"'"i^tration  of  the  ex- 
ict  of  the  gland  to  patients.    The  disease 

|en  treated,  and  the  results  arc  not  as  'yet 
I   ny  means  assured.     I  liave  had,  for   he 

|n  Mh.ch  has  improved  in  a  very  ren.nrka- 
I  nu.nner.     1  he  followincr  is  an  ai,stract 
hs  his  orv:    Wm.  H..  a^xl  46,  sril-iS 
I  was  adn^.tted  to  the  Johns  Hopkins  ITot- 
!"'•  '^lay  3,  1895,  suffering  from  cough, 


f  th    s  i'  '"  v'"!  "'■'■^'^^'"S:  pigmentation 

•vug  had  tubercul,  MS.  At  the  age  of  16, 
V  nonboanla,nan-.,f.vvaratl'anan.a.he 
S  '  ''"''^"'^  ;^' jann,licc,  and  he  says  his 
or  si.  CO  r.'r ''''"  '"  •'  P^''-f^^^-tly  good  col- 
run  over  '''''•  '"l"'.vofi8g3lK'was 
across  fl,    /-■,'  ^"^""'  tl'<-'  ^vhcel  passing 

..s  had  ind.ge.siK,,,  ,„r  several  years.     Iv.r 

m>m.;V  J'l'  "'■'■'"'  •"'  i'K-reasing  pij.-- 

;''y"ofthesk,n.    Within  the  past' sLx 

"lOlUllS      e  ll.'l-,    ri.     1    I       I      f  1  . 

.111,,- .  ' ''  ^"'5''  ''^'•'''  of  coucfh  and 

i;  u'^  ^-1-^.  .ration.     On  !dmis- 

ranlhr'''-''^"''''--'"^^'>'^^«^^-^'-^^^"'''<- 

tion  o    1,      /■■'"  ''•''''"''^•''^■-     '^^''^"  Pigmcnta- 

on  H,^,^   '"  T'^  '''-y  '"^'•■"^^^''  particular- 

,;"      '    '''"••  .f'^'-.^'"'-'^!'  '•^"<Is.  axillae,  el- 

I  i     of  h!o?  "'/"I'l'i-^.  and  genitalia.  The 

ored     T         "'"''  ;^'''^  ""'  -^^  "'"^-'i  ^Iis«>l- 
roof  of""'  ^^•'''^■^'^^•l"  pi.g">cntation  on  the 

Id   the?'   u      ■  ';"'-•  ^vas  of  fair  tension 
: 'Hi   the  wall  o(  the  artery  not  thickened 

The  e  .^'  V""","'''"">-  '-'"^l  ^-^i'lary  regions, 
o  tl  e  yer  ^"'''""^•.''"^"t  of  the  splJt.,,  or 
ot  the  Iner.  no  special  tenderness  over  the 
region  of  the  suiirarenals.  The  sputi  m  w  is 
8,^1-^^  yellow,  but  did  not  coiS"^ 
Uastic  tis.sue  or  tubercle  bacilli. 

I'rom  the  date  of  a^hnission  to  May  'i6tli 

ue    lecs  1  .    On  :\Iay  16th  he  becran  to  take 

he  gained  five  pmuvN— an  mrvn-;.      c    ■ 
and  a  lialf  poulids  sii.ce'i^^S;;;   -- 
^Sm.   I  he  pulse  .gradually  fell  from    04  S 
84.  the  sputum  decreased  to  ^o  r,  Kil     "^  ! 
metres  daily,  the  anneti^e  inVrme     .  TJ" 
patie,.,ookedveryn,uc;rC?'K;;l^ 

^nnecf'^lid'ir;^^  nt^SS":n^^r°;f 
audinweiVht     He  losrl";  i'e  ;\    "^1 
apathetic  appearance,  and  his  bodil?  ' 

improved  greatly.  °''''>  ^''^or 


"S   Ul^jl 


There  was  no  change    emphasized  the  fact  that  the  qncstion  is 


On  September  loth  he  left  the  hospital, 
the  change  in  his  -r  ulition  being  in  every 
way  remarkal)lc.  He  had  gained  nineteen 
pounds,  was  bright  mentally,  and  vej-y  ac 
tive  and  vigorous, 
whatever  in  tlie  pigmentation. 

I  showed  this  patient  at  my  clinic  exactly 
eight  months  after  the  beginning  of  tlie 
treatment.  He  continues  well  and  strong. 
He  has  no  longer  any  cough,  he  attends  to 
his  business,  and  says  he  feels  perfectly  well. 
There  is  no  essential  change  in  the  pigmen- 
tation. 

Time  alone  will  tell  whether  we  can  ob- 
tain by  this  metliod  of  treatment  the  brilliant 
results  such  as  we  have  in  myxedema  with 
the  use  of  the  thyroid  extract.  It  is  not  at 
all  probable  that  tlie  results  will  be  uniform- 
ly good.  In  the  first  place,  tlie  lesion  of  the 
adrenals  associated  with  Addison's  disease 
is  often  only  a  part  of  a  general  tuberculosis 
In  advanced  cases,  therefore,  the  suprarenal 
extract  is  not  likely  to  be  of  use.    In  cases 


ment  will,  of  course,  be  fruitless.  In  a  ;.  w 
instances,  however,  it  is  cpiite  possil)le  that 
the  progress  may  be  checked  or  tliat  tlie  dis- 
ease may   be   i)ermanently   cured.     I   liavcl 


in   the   tentative   stage.     The   experiiiicntall 
evidence  has  not  that  strong  ancl  powniulj 
unaiiimily  such  as  we  have  noted  in  the  i  a^J 
of  the  tliyroid  gland;  still,  it  is  extI•eliil•I\^ 
suggestive  of  the  view  that  the  adrenals  ar. 
important  functional  glands,  furnisliini' 
internal  secretion.     If  the  symptoms  ni  tht 
disease  are  directly  dependent  upon  du  ab| 
sence  of  this  internal  secretion,  then  in  -int^ 
able  cases  the  extract  of  tlie  gland  may  sup 
ply  this  defect,  and,  as  in  the  case  of  niyx 
dema,  arrest  the  progress  or  even  cure  tb.; 
disease.     The  cases  treated  so  far  nuinV^' 
only  eight  or  ten,  and  I  think  it  may  be  .  r 
that  in  a  majority  of  these  the  condition  h. 
been  iniprove<l,  as  in  the  case  I  have  men- 
tioned, but  I  do  not  know  of  any  instance 
in  which  all  the  symptoms  of    the  diseasd 


pvtrnrt  is  not  llKeiV  lo  ue  ui   iinv;.     -m  vc».^._.t     ...    ,,...^  ,    -    ,.'  i 

associated  With  malignant  disease  the  treat- 1  have  permanently  disappeared. 


A 

X/ 
\// 
/ 


i 


.i< 


i<.i^ 


7/U 


w 
u 


.^  c 


9 


£  7"^/^^*^^  Lf^' 


t' 


'\\S^\ 


IaTCv^-i^      "t 


^lA. 


u\ 


i.  H'i 


Dth  lie  left  tlie  hospital, 

Diidition  being  iti  every 

le  liad  gained  nineteen 

nuMitally,  and  very  ac- 


i:...i 


ment  will,  of  course,  be  fruitless.  In  ;i 
instances,  however,  it  is  (|uite  possible 
the  progress  may  be  checked  or  that  the 

,..,..„..., J  ...      ease  may   be   permanently   eure(|.     I   li.,,,. 

There  was  no  change    emphasized  the  fact  that  the  question  is  ,iili 
nentation.  I  in   the  tentative  stage.    The  experimcni,il 

lent  at  my  clinic  exactly  i  evidence  has  not  that  strong  an<l  powiriiil 
tile  beginning  of  the  unanimity  sucli  as  we  have  noted  in  the  iiim. 
tinues  well  and  strong,  of  tlie  thyroid  gland;  still,  it  is  extninrly 
ny  cough,  he  attends  to  suggestive  of  the  view  that  the  adrenals  arc 
's  he  feels  perfectly  well,    important  functional  glands,  furnishinj;  m 

internal  secretion.  If  the  symiHoins  ni  tlu: 
disease  are  directly  dependent  upon  the  rih- 
sence  of  this  internal  secretion,  tlien  in  suit- 
able cases  the  extrac  t  of  tlie  gland  may  sup- 
ply this  defect,  and,  as  in  the  case  of  tiiyxo- 
dema,  arrest  the  progress  or  even  cure  the 
disease.  The  cases  treated  so  far  nunih.r 
onlv  eight  or  ten,  and  I  think  it  may  be  Miid 
that  in  a  majority  of  these  the  condition  ha- 
been  improved,  as  in  the  case  I  have  nicn- 
tioncd,  but  I  do  not  know  of  any  instance 
in  whicli  all  the  symjitoms  of  the  disease 
have  permanently  disappeared. 


1  change  in  the  pigmen- 

ell  whether  we  can  ob- 
of  treatment  the  brilliant 
lave  in  myxedema  with 
)id  extract.    It  is  noi  at 

results  will  be  uniform- 
t  place,  the  lesion  of  the 

with  Addison's  disease 
•f  a  general  tuberculosis, 
herefore,  the  suprarenal 

to  be  of  use.  In  cases 
ignant  disease  the  treat- 


i 


.1. 


'i,^^ 


9 


l)h 


ti 
Ml 

I 


I 


£         7~i^/>^-^^**'^  t*'//' 


t 


c 


.t< 


[at^^  ^'^     ^    ' 


.  i       Hi" 


riiitloss.  Ill  a  !■  ,v 
|iiitt'  possililt.'  I'l  It 
ictl  (ir  tliat  the  ^1:- 
y  curc(|.  1  li.ivi' 
lie  question  is  ^u\\ 
Tlic  t'Xl)criiii(tiial 
oiif^  ami  powuiul 
e  noted  in  tin:  r;is, 
II,  it  is  extreiiiiK 
It  the  aiireiKils  ;in' 
ids,  furnisliin-  ci 
•  syinptonis  >i\  ^\\^ 
ident  upon  the  rib- 
etifin,  then  in  suit- 
he  f^land  may  sup- 

the  case  of  iiivxe- 
i  or  even  cure  the 
:ed  so  far  nunihi  r 
link  it  may  lie  said 
.'  the  eonditinii  ha. 

case  I  have  nu'ii- 
nv  of  any  instance 
ms  of  the  disoase 
pearcd. 


v 


(s^'fU*, 


L  uv./- 


■\ 


|:^ 


i? 


^%l 


O} 


Pr< 


%/%'^ 


L-   X-|; 


TIVE 


;^^'^|TONITIS.     AND     RHCURRING 


ASCITHS,     WITH 
OIUM. 


ADHHRHNT    PHRICAR- 


'^V    Wll.MA.M    (Jsil.K.    M.I)., 

Professor  ol   .Vledirinf    i    i        i, 

•wt^'licine,  J  ,h„s  Hopkins  Univcrsitv   I'h      •   ■        • 


[I 


'  ':¥ 


'iV    WII.I.IA.M    OM,(,K,   M.„. 
f'-ressor  of  M..„i.,ne,J,.hns  „,,,,,„,„.;       ... 

'"'"itn.l  valve  lesion  with  consecutiv    -  '  ''"'  "'°''  ^'^'^^"-^"^'^ 
cMtlHM-totheatropln-,consec,e       ,        H     '■"^^''  '"  ^'^'^  ''^'^'•'  due 

■n  adults  to  an  ai.oc;at:;Z        '  ^H  ^^^'^'^^'^  '"'^'^"^'°"'  - 
also  in  children,  in  which   the  ,.•  /      "^'-^'''•^ '"'''' '"stances 

"'"^^^'y,    a  chronic   pro    .  -,    V  n    ?  "  '"'  ''  ^'""^'^^^  ^^'^•^'^: 
hepatitis  and  peri-splenit,s  "'^"""^  ^'"'^  extensive  peri- 

univX'f;;;.;;;;;r;-,^:;:;:,;;,;-'d^^ 

f-t-vorrecurrin^attacJo    ,  1^^ 

la'Sed  heart,  and  a   loud  apev  .  ■     l        '''^^  '  ^e.^v  j?reatlv  en- 
observation  tor  a  lonu  t,n    "n        t  /""'T''     "'  ^'^"  "'^^' 
dropsy  was  limited  to  the    er  tone  n       ^'^7^"'   ^'^P'^^^'^^'^-     ^he 
a-s  one  of  old  nmral  dise  se  w  t        "    T  ""'  ''^''"^'^  ^'^^'  '^'^^ 
The  autopsy  show   i   :;nlu  ,  "n'"'' ""'^^'^  °''^'^^'  '--• 
Perieardiun.,  an  onornnn  s  v      h  'e    h  ""I  '"V'  ^'"  ''^'^'^''^ 
a  chronic  proliferative  per  o  ui  ' wi  ^0   without  valve  lesion. 
splenitis.     The  case  was  „nu        n  ^    l^:-':''''\  ^'"^'  ^'-'- 

•-'-n,onths.urn,:;!;:'L.:::;7;::;::r;;r^^^^ 


Ma 


(fiul   Ik  f,, 


(■   I  lie    A  lilt; 


i;aii    Pediatric   S. 


(irictv. 


ii-.tpnia 


Hot   Spi 


"■W^!t»'^Aft'«BK*-fi«'i 


H 


1 1 


ui  ?! 


ill      f      g 


t! 


3  Osi.ER  :     Enormous  Heart  Hypertrophy. 

Ward  G  of  the  Johns  Hopkins  Hospital  from  May  14.  i^g''  to 
Doa-inluT  «,  1894,  a  period  of  more  than  three  and  a  half  years, 
her  a^e  on  tirst  admission  being  eleven  years;  at  the  time  of  her 

death,  fourteen. 

Pm'ious  History.— There  was  no  history  of  acute  rheumatism 
or  of  St.  Vitus's  dance.  She  had  had  measles,  scarlet  fever,  and 
whooping-cough.  On  questioning  the  mother  closely  about 
rheumatism,  she  says  that  Louisa  had  at  one  time  growing  pains 
in  the  legs,  and  the  muscles  of  the  right  .irm  were  once  so  stiff 
that  she  could  scarcely  use  it.     The  joints,  however,  were  never 

swollen  or  tender. 

Onset  of  Illness.— About  May  i,  i8qi,  she  began  to  have 
short  niss  of  breath,  with  swelling  of  the  feet  and  of  the  abdomen. 
Nothing  abnormal  had  been  noted  before  this  time.  On  her  fust 
admission  there  was  orthopnoea,  general  anasarca,  cyanosis,  and 
extreme  ascites,  so  that  she  was  tapped  at  once,  and  over  three 
litres  of  clear  fluid  were  withdrawn.  There  was  enormous  hy- 
pertrophy of  the  heart,  with  great  bulging  of  the  praecordia. 
Theie  was  no  thrill,  but  there  was  a  very  loud  blowing  systolic 
murmur  at  the  apex,  rough  in  quality,  and  transmitted  to  tlie 
spine.  The  murmur  was  heard  also  at  the  lower  sternum  and  at 
its  left  margin.     The  pulmonary  second  sound  was  accentuated. 

The  child  improved  a  good  deal,  and  the  d-dema  of  the  feet 
disappeared,  but  the  swelling  of  the  abdomen  persisted.  The 
spleen  could  be  felt  below  the  costal  margin;  the  liver  was  en- 
larged, the  edge  only  one  inch  from  the  transverse  navel  line. 

The  case  was  regarded  as  one  of  mitral  valve  disease  with 
secondary  enlargement  of  the  liver.  On  the  I'lrst  admission  she 
remained  until  August  29th,  and  improved  very  much.  A  few 
days  before  leaving  the  note  reads  that  "the  ascites  has  disap- 
peared, the  heart's  action  is  regular,  the  pulse  72,  and  of  medium 
volume.  The  apex  beat  is  in  the  sixth  space  in  anterior  axillarv 
line;  there  is  a  wide  area  of  heaving  impulse  as  high  as  the  third 
rib.  Tnere  is  a  systolic  thrill  at  the  apex,  and  a  loud,  musical. 
systolic  murmur  which  is  transmitted  to  the  back,  and  the  pul- 
monary second  sound  is  intensely  accentuated." 

We  had  no  other  idea  about  the  case  than  that  it  was  one  ol 
mitral  insufficiency,  though  the  question  came  up  on  several  oc- 
casions whether  or  not  she  had  in  a.ddition  adherent  pericardium. 

She  was  readmitted  October  8,  1891,  with  great  shortness 
of  breath  and  ascites.    She  was  tapped,  and  nearly  three  litres 


Osi.kk:     E„o,-n,o„s  Heart  Hv^,  /    ., 
;'K;iin  removed.     She  wis  \- 

f'^^  l^^'nds  .nd  leet.  Th;c:„.ni  nIv"  ?'""''^'  P^'^^'-^^^'^'rlv  in 
~^'  'Olid,  roLiiih,  apex  svsf  i  '  '""'  "-"-^  ^'^-'•'-'  the  same 
7--  'nd..,.,;,^,:;:;:;;-;-Mn,ns„.ttedwe.,to;h: 
^'^■"nite  murnn.,-.     There  v  .,s  ■."  '  '''''  '■^'""^''-^  '^'t  no 

■^'^■mnl  rei,non,  but  no  specTildiir.  "  '""'■'"^"'  ''"  ^'^^^  'ower 

'H'al.ne  casts.     Verv  11,1!  no  e  ^    "'  '  T  f  ^""'^^  granular  and 
P^-'-t'cularly  with  reference  to  th  ':''-:  °' *'^^' '^^'■^^  ^'t  intervals. 

^'Pex  beat  seemed  to  have  lowenH  '°'\     ""  "'  ^'^^  '^'^^'«-     The 
-^tb  space   7  c.  n.  outsideX :^ppi:'  '''''  '^  '^'^  '"  tbe  sev- 

Throuirhout  the  summer  of  ■No;  .h 
occasions,  and  the  condition     e   ",in  d  T  '''''"^  '"  ''''''' 

-X';h:r::::;:;^:--:^'--nune.,s..itw^^ 

loud,  musical,  systolic  murmur  whH.'  u'^P'  '^''^^^^^  ^^y  ^• 
^'x-lla  and  back,  having  at  t  sc^  ^''■^''''^  throu,.hout  the 
j'cter.  Passing  upwards  an  , ^^ Vo"  T"''  "^^'"^  ^h^'^" 
!ost  its  musical  character     Tl  "  s  "''  'P^'"'  ^^'  '^'-'nm>. 

feebly  at  the  apex,  was  inten  e  v  '  °"  Z'"'";^'  '''^''^'  ^^'^  ^eard 
t--^^Pace.     The  sounds  in  «  '   '""    ''"^  '"  ''''  ^'^''''^  '^'^  *'- 

;i-t  time,  just  before  her\  h  ^olT'^  """  ^'^"^-  ^^^  ^^^ 
l^^'t  of  the  sternum,  a  doubi    m   '  J,,  ,  ""'"^  '^"'^'''^^'^  ^°  ^he 

behind,  as  it  were,  the  ac    n  ul  ""f         '^'  '  ''^'  '^''''''^^'' 

•'-^'^  sternal  border  th^mr::;::::::;^;-:;"  '^^'^^'"^'^^- 

-r;;^Et^t^;-  ^^^^^^^^^  P-l.     The 

She  was  readnmted  o.kS^  :    ,  "fso/  "'?'• 

continuously  in  the  hnspif,!  until  h,/,  ,^  '  '""^  ''emained 
During  this'entire  period  si  e'^Kth"  .""'"'^'^^  ^'  '«'^4. 
fe'ture.  Prior  to  th,s  ^llnS^  ^  V^  ;::'f  ^'1  ^^^"^'"-^ 
or  four  times,  fo  December  7  hh  '  '"\^^'PP'-^d  o"'y  three 
was  tapped  n,  fmes    m     .      '     '  '^  ^''*^'''  '^^''  ^eath,  she 

on  each  occasi  n      We      0  :;!;;     T'^'  ^^  '"'''^''^  ''^'^^' 
^'^fi^erent  pericardiu^as  2.    .!':!!J"  *''  P''°^^'^^"'»y  ^^ere  was 


Th 


of  tht 


lere  was  systolic  retract 


icfion  in  the  a 
praecordia,  and  the  upper  li 


well  as  extreme  mitral 


insuflicien 


cy. 


seemed  very  fixed 


pex  region,  marked  bulging 


PPer  limit  of  pulmonary  reson 


ance 


4  Osi.er:     Enormous  Heart  Hypcrlropby. 

Diirin.r  these  hist  two  vcars.  the  condition  of  the  liver  in- 
terested us  very  greatly.  When  the  abdomen  was  emptv  the 
organ  lornied  a  visible  and  actively  pulsating  tumor  niidway 
between  the  navel  and  the  costal  border;  and  it  is  well  figured 
in  my  lectures  on  the  diagnosis  of  abdominal  tumors.  It  was 
smooth,  descended  with  inspiration,  and  expanded  visibly,  ts 
edge  was  rounded  and  the  whole  mass  could  be  grasped  in  the 
hand,  teeling  like  a  large  spleen.  The  edge  passed  beneath  the 
ri-rht  costal  margin  about  the  nipple  line,  and  tar  over  on  the  lett 
costal  margin  the  enlarged  spleen  could  be  felt.  Grasped  in  the 
hand,  the  pulsation  was  expansile  and  forcible,  a  little  later  than 

the  cardiac  impulse. 

Early  after  her  admission  on  this  occasion,  there  was  telt  toi 
the  first  time  also  a  distinct  peritoneal  friction  rub  just  below  the 
edge  of  the  liver.  The  condition  of  the  heart  did  not  materially 
change,  except  that  the  area  of  dullness  increased.  The  loud, 
intense,  apex  systolic  murmur  persisted,  and  was  heard  all  over 
the  right  side  of  the  chest,  in  the  sixth  space  a  little  above  the 
nipple,  there  was  a  rumbling,  echoing  sound  occupying  the 
entire  diastole,  and  in  a  limited  area  this  had  almost  the  charac- 
ters of  a  presystolic  murmur.  The  first  sound  was  always  well 
heard  Along  the  left  sternal  margin  the  soft  diastolic  murmur 
already  mentioned  was  well  heard.  It  was  not  aidibie  at  the 
aortic  cartilage,  but  in  the  third,  fourth,  and  fifth  interspaces  on 
the   left   side.     She   never  had  general  anasarca  after  her  hrst 

admission.  ,  ^       .  •    u 

There  were  two  additional  features  of  great  interest  in  her 
case  It  was  noticed  on  her  first  admission  that  the  cyanosis  of 
the  hands  and  feet  was  extreme.  This  persisted  with  but  little 
change,  no  matter  what  her  general  condition  might  be,  whether 
she  was  suffering  with  great  dyspnoea  or  whether  she  was 
wheeling  herself  about  the  ward  in  a  chair,  the  hands  and  feet 
were  permanently  cyanotic.  She  became  very  thin,  but  the  ex- 
treme lividity  without  any  oedema  was  a  remarkable  feature  in 

her  case.  .•     j  *u  . 

Then  shortly  after  her  last  admission,  it  was  noticed  that 
subcutaneous  fibroid  nodules  were  developing,  and  a  series  ot 
these  appeared  about  the  knuckles,  the  wrists,  and  the  elbows. 

As  1  have  already  mentioned,  the  primary  lesion  in  this  case 


^D.  Appleton  &  Co.,  New  York,  1894. 


he  liver  in- 
empty  the 
lor  midway 
well  figured 
IS.*  it  was 
visibly.  Its 
asped  in  the 
beneath  the 
er  on  the  left 
•asped  in  the 
tie  later  than 

t  was  felt  lor 
ist  below  the 
ot  materially 
The  loud, 
leard  all  over 
tie  above  the 
:cupying  the 
;t  the  charac- 
;  always  well 
tolic  murmur 
tudibie  at  the 
;iterspaces  on 
liter  her  first 

nterest  in  her 
le  cyanosis  ot 
vith  but  little 
it  be,  whether 
ther  she  was 
lands  and  feet 
n,  but  the  ex- 
ible  feature  in 

s  noticed  that 
nd  a  series  ot 
1  the  elbows. 
3n  in  this  case 


\V''-^  thought   t(,  he  niiini  .c\ 

^^y^''-,  :ind  enon.ou         ;  X^ 

'"  t'l^'  nght  eh:,n,hers.     Th  '   ''yP^''"ophy  and  dilatation 

P-'c-dium.  and  as  the  p      ,  t    ;;r^t^'^^''"'-^  ''•  -<l-r^^ 
:^^.  'ver,  with  reeurnng  a       •  '    i7"^"""^'  "  ^'^■■^""<en,  cake- 

.•e.be-gerusch,-„ui  re,ne„„       ;,;"',  ;'   ^^■^"-"-•'<-i  peritoneal 

•■^'ty  Hospital.   I^hiladelphia    I     '  h  """' '''"'  ''  '^''  ^"'■^'^''•- 

Pentonitis  with  per,-hepa„iK  .n    tri'     l'^""'"'  "''  P'-o'"^'-^'tive 

'^'y  to  the  adhere,,,  pe.l.ndiu,        '^"'"^^'-"^'■^'  --ondary  possi- 

'he  child  died  on  1)  ■  ■      i  ' 

f^'PPin^;  the  respi,-ations^b;™n'et!'''-''r'''^''''^^'''^--  '^'^t 
'^-saction...„.,,,,,,J-^;;^^ 

'/''■/  '"ng~cuonuous  Inpertro      '      '    P>-'^f>-^Unm,    diaphragm, 

t'l^lc-dilatation  of  ,-..7..  ;  Vf^--''''^'''-;'-''^^'-''  of  left  ven- 
'-'^'onn- proliferative  pcrifoniii  ft  1'  ,™"  ''"^"^'^  ^<^fi^nents~ 
^:s~~eirr,os,s  of  tke  /i.v;i!t;;  '' f"'"^'^"^'^"  a>ui peri^.p,,,,,. 
"'^^stines.  sto,uarl,,  .>ut  tuJnTjT^''''^''^''"  of  t1,e  spteen . 
^^nd  hands.  >''^^"0~/iho„s  nodules  about  tlw  elbozes 

The  body  was  much  e,iiaciated-  the  l.. 
^'tous;  the  veins  we.-e  p,-o,nin         h,      ,     "    "^''^  '  ''»'^'  '^"^^'-'•"- 
'"•'f  ='nd  legs  had  d.s.lpp  '•  '  '/'^'  ''^'''^'  ''^'^^''^y  of  the 

•'"^' there   was  a  p,-o,.i,l^,,;  t.ul  ^  ^  f "?  ^"'^  ^^'^^ended 

'^upe.-f,c,al,  abdominal  and  tho,-,cL"n  ''  '"'''"'^^-     T^e 

were  subcutaneous  fib.oid  nodi  , .  V  '  '''^''■'•:P''°'"ine"t.    There 

-ion.  rheparietX'  l:  :^  r:  .r^''';'"'  ^°  ^'^^  ^— - 
'n  many  places  cove  ed  w itl  1^^^^^^^  'ts^'"  ""^'extent  was  opaque, 
"'"■ous   tissue.     The   i^      r       "■  ^  '^'^^^"'"g^  ^'"^^  threads  of 

opaque  and  thickened.  ^Un2"^7''^''''''''^  '''  ^^^'^°^^' 
^"nl^'-ged.  The  spleen  w,  ,Wl7  ?  '"^'  "''  ^'^''^^^'-^'l  were  not 
"■■■e.u,a,ly  thickeiec^ a,::;^'^^:  J^';^  ''''''''^'  "^^'^ 
m  consistence,  and  dark  in  color     liu   ^       T  ^''"'^  ^'^  ^'^"^^ 


6 


Osif.r:     Enormous  Heart  Hypertrophy. 


It  w;is  much  deformed;  without  clear  separation  between  the 
ri,i,'ht  and  left  lobes,  but  the  whole  organ  was  enveloped  in  a 
thickened,  pearly  white  membrane  of  from  two  to  five  mm.  in 
thickness.  The  gastro-hepatic  omentum  was  also  thickened. 
From  the  hilus  of  the  liver  thickened  bands  of  fibrous  tissue 
passed  with  the  portal  vessels,  and  in  some  places  the  Glissonian 
sheath  was  greatly  thickened.  The  liver  tissue  itself  was  greatly 
altered  in  appearance;  the  cut  surface  was  dark,  almost  black, 
with  here  and  there  light  areas  apparently  of  fat  tissue.  The 
central  veins  of  the  lobules  were  dilated.  The  length  of  the  liver 
was  1 5  c.  m. ;  thickness  6  c.  m. ;  width  lo  c.  m.  The  consistence 
was  greatly  increased.  The  hepatic  veins  were  enormously  en- 
larged, and  even  in  the  middle  of  the  organ  they  easily  admitted 

the  little  finger. 

The  kidneys  presented  a  markedly  cyanotic  appearance;  on 
section  there  was  much  congestion,  the  consistence  was  much 
increased,  almost  of  stony  hardness.  The  mucous  membrane  of 
the  stomach  and  intestines  was  greatly  congested.  Otherwise  it 
showed  no  special  changes. 

Thonix.—The  heart  occupied  an  enormous  space  in  the  front 
of  the  chest.  The  intercostal  spaces  were  dissected  out  so  as 
to  get  accurately  the  limits  of  the  heart  m  situ.  From  the  mid- 
sternal  line  the  following  w  .re  the  measurements:  In  the  second 
interspace  to  the  right,  6  c.  m.. ;  to  the  left,  8  cm. ;  third  inter- 
space to  the  right,  8  c.  m. ;  to  the  left,  1 1  cm.;  fourth  inter- 
space to  the  right,  1 1  c  m. ;  to  the  left  15  c.  m.,  so  that  the  total 
transverse  measurement  of  the  heart  in  the  fourth  interspace  was 
26  c.  m.  (10^  in.).  In  the  sixth  interspace  the  right  border  of 
the  right  auricle  is  11  c  m.  from  the  median  line,  and  the  apex 
was  14  c.  m.  (6  in.).  The  right  auricle  was  enormously  large, 
and  (before  removal  of  the  heart)  measured,  in  an  oblique  direc- 
tion from  the  tip  of  the  appendix  to  the  orifice  of  the  cava,  just 
above  the  diaphragm,  14  c.  m.  (6  in.).  The  front  of  the  heart 
was  formed  almost  entirely  by  the  right  chambers.  The  peri- 
cardial sac  was  partly  obliterated  by  old  adhesions,  which  were 
situated  particularly  over  the  right  ventricle,  involving  the 
left  ventricle  only  a  short  distance  beyond  the  septum.  The 
greater  part  of  the  right  auricle  itself  was  free  and  the 
whole  of  the  posterior  surface  of  the  heart.  The  adhe- 
sions were  composed  of  strong  fibrous  bands.  The  right 
auricle  was  enormously  distended  and  filled  with  partially  decol- 


/  ' 


Os'kr:     Euonnoits  Heart  n  .    . 

til  art  Hypertrophy 


orized  dots.     The  will-  ' 

endocarciiuM,  vv.s  opaque  ''■!-?''  '  •""'^''^^"  "^'^■'<^ "-''  '"id  the 

c^'va  trom  the  auricle  o,t   s  .w    r  '"  ^""^''^■'•'  '^^«^'"K  intoThe 
greatly  dilated  hepatic  ve    s    Ithn'  ^  ''"'^^  op^i^n.s    ^ 
;^   Passed      The  coronary     is   w''  l'^"  '"^^'^  ''"Ker  could 
the   foramuia    Thehesu'    Were    u ,      V"'"  ^"■^'^'^'>'  ^l''"<-'  "nd 
ventncle  was  much  dilated     ndhr'    '^'''^''''-      '''''^'    ''Kht 
«••''-"  was  lar^e;   ndmitt^i    ^    ^r"'"'^""'-     ''""^  '^^^^^ 
miisxles  were  thickened  and       ttTV""''^'-     '^'^^  f'^'P'"'v 
thickened  and  tlattened.     The  t      '  "  '  "''  f^'l^^'^ulae  likewise 
,^-e  a  little  opaque  but  no    s     unT"'^  ""l  ''"  ^^'^'H^id  valv 
'omm  was  closed.     The  (I     In  '"•     ^'^'-' ■'^^'Pt^'m  ventric  . 

--  8  mm.;  the  len,  ,'  :^";"  "'^'^  -'"  of  ri.ht  vJ^  ^^ 
^l^e.  The  valve  se^..;,;  ^^^'J^^^  ^-'"--"7  '.-tery  wa^ 
'eft  ventncle  was  not  nearly     'i  '"^'  ^'^'^  ^^'t^r.     The 

c-  '". ;  thickness  of  the  nn     ul  ,  w  f  '''  "^^'  '•'^''^^;  '"-'-^^-red  8 
ments  were  not  shrunken    h      1     '  '?'"'"•     ''''^^  '"'tral  se,.- 
"-■"-'•     The  nmral  orilic  "a    l^^'fj'^'^"^-  throughout   th.t. 
the  point  of  insertion  of  the  do        \    V'"'^  '  h^'""  "ngers.     At 
ments  there  were  a  few  c  Ic  ,le     '         '"^'""^'  ^^  ^'^e  n.tral  seg- 
;;;-cle  and  the  trabecU^  w   ^\  ^l^  ^^  ,  ^"'^  Posterior  papi„a^ 
the  left  auricle  was  opaque  Z    i    I      '.    V''  endocardium  of 
W'.s  not  specially  dilatej.     T    !    '  ^  f"'^^ '  ''''  the  cavity  itself 
segments  were  not  specially  thicken  'l  '^"^  '^''''-     ^he 

which  was  thickened,  and  thi    1  '""''^^  ^^e  middle  one. 

'--'  clilatation  as  lar^;  '  ^"u^^r'  rT'''  ^'  ""'"  ^'"'^"^- 
;"tery.  The  aorta  i.:;t  aboyf  /he ".r  ^^^'  '°°'^  ^^""^^'^  ^^e 
t^^i-ence;  at  the  end  of  the  arch    ,  -  ^"'  ''  '■  '"•  "^  ^"''-•^'ni- 

''"g'oma,  In  other  places  the  iv,'"  "^''^  almost  like  an 
•he  increase  of  conne  t  ssu  w  "":  T"  '''''^'  P^^-'-ed. 
scribed  thick  bundles.     Tl  e  Is    ?  ""  ■ '^""^'^'  '^"^  "i  circum- 

tncle  showed  a  moderate  d^rcT  V  I  ""'  ^'  '''  ^'^'^^  -""- 
much  more  marked  than  on  fh,;  "'-/''"f '^^^'^'^^nerat.on,  which  was 


Remarli: 
tion  with  th 


-Th 


on  the  left  side 
ere  are  many  points  of 


's  case,  but  /  only  can  refer  h 


great  interest  in  conn 


r 


lere  to  the  recurr 


lec- 


8 


Oslf.r:     Enormous  Heart  Hypertrophy. 


iiscites  with  proliferative  peritonitis.  The  c;.se  is  ahnost  the  ex- 
act counterpart  of  the  one  uiuier  niv  care  in  i'hiladelphia. 

Chronic  proliferative  peritonitis  is  met  with  chietly  in  adults 
under  conditions  similar  to  those  which  produce  cirrhosis  of  the 
liver.  It  has  been  in  my  experience  a  rare  disease  in  childhood; 
and  in  the  adult  the  svmptoms  are  in  reality  those  of  atrophic 
cirrhosis  of  the  liver,  and  the  diagnosis  is  very  rarely  made  before 
death. 

Rosenbach  is  the  only  author  I  can  find  who  suggests  the 
possible  connection  between  adherent  pericardium  and  a  chronic 
peritonitis;  and  he  thinks  that  the  chronic  proli'erative  process 
extends  along  the  veins,  through  the  diaphragm,  and  involves  the 
peritoneum.  It  is  not  unlikelv  that  in  the  case  here  reported  this 
sequence  may  have  occurred.  Some  of  the  cases  of  indurative 
mediastino-pericarditis  present  a  very  similar  clinical  picture  (see 
Harris.  Meiiicat  C/jroiiute.  189s). 

Other  points  of  great  interest  in  the  cases  were :  The  enormous 
hypertrophy  and  dilatation  of  the  heart  with  only  partial  pericar- 
dial adhesions;  the  clinical  picture  of  mitral  valve  disease,  which 
most  of  these  cases  of  adherent  pericardium  preser '  so  soon  as  the 
cardiac  dilatation  becomes  excessive;  the  diastolic  murmur  along 
the  left  sternal  margin  which  was  probably  associated  with  in- 
sufficiency of  the  valves  of  the  pulmonary  artery— Graham  Steell's 
murmur  of  increased  pulmonary  tension;  the  subcutaneous 
fibroid  nodules  in  a  .i.ild  who  had  never  had  acute  arthritis  and 
who  had  no  mitral  valve  disease;  and  lastly  the  remarkable  tumor 
formed  by  the  pulsating  liver. 

I   WksT  FkaNKI.IN  STKHI/r. 


(Ll. 


yy 


ost  the  ex- 

hia. 

ly  in  adults 

hosis  ot  the 

childhood; 

ot"  atrophic 
nade  before 

.up;pests  the 
id  a  chronic 
ive  process 
involves  the 
L'porled  this 
f  indurative 
picture  (see 

le  enormous 
■tial  pericar- 
ease,  which 
I  soon  as  the 
.irmur  alon<{ 
ed  with  in- 
ham  Steell's 
jbcutaneous 
arthritis  and 
kable  tumor 


"""""" "" '-i'r^i:!^- M.» ...„,  .„„ , 


■ly.  1896, 


Hemi|)le,!ria  j,,  Tv,,|,„i,|  |.-,vcr. 


HV 


\VILLrAM   OSLER,  M.D., 


Professor  or  M..lic.i,K.,  John  Ilopk.ns  diversity,  rw. 


iiiioro. 


^\ 


i^'f 


'"''^"''M:<;I.A   IX   TM. 


Moil)  l'|;\-i.;K. 


"^-  Wir.MA.Mosi  MK 


.  M.n 


I'riilcssoi   , 


'"■ ' "■"■^ -,.,.,,.,„ „ 


orn.sof  paralysis  n>o  ',^0;;:"  ""  '''ackhoanl  f '!;!: 
a  ter  the  specific  fevers  "  -^  "  '  ^^•''"^  'luring- a„d 
varied  ,n  their  svmnf,  r'  <  ■  ""   ''•^■>    ^''^'V  are Ver 

"afm-e  of  the  local  S  '  " ->-'"^'  varicl/t-u,    .^   ,^i 


SVMJ'Tom.s, 


I  Ileiiiipletjifi. 

Paralyses 

during  ^S:  , 

after  fev-  J  ^^''aplegia. 

ers.  1 

Diplegia. 


Monoplegia. 
[  Local  paraly? 


ses. 


r.KsroN. 

!^5is'"'--='rs. 

I  inL-nioirhago 

;  j;:s^;-"p'-Htis. 

(  ^'eiiritis. 

'  \-       •  . 
,  -Neuritis, 

.'  ''o'io-myelitis 

'  ^'euritis. 

'  Neuritis.  .'  Toxij. 

'  Myositis,  '  ''"essure. 


We   can    divide   the 

Phc  ai    esions,  affcctino- 
^^ena,  sniall-pox,  ,S 

'A  clinical  lecture  ..irtlu.joh 


as  Hopkins  Hospital,  Dec. 


'«95. 


A  uv/j./.u/  os/.r.k. 

fever,  the  palienl  may  become  hemiplegic  at  the  height 
of  the  disease,  a  condition  which  may  be  preceded  by 
convulsions.  In  reviewing  a  large  number  of  cases  c)f 
hemiplegia,  particularly  in  children,  one  meets  with 
manv  instances  in  which  the  paralysis  has  developed 
during  the  course  of  one  or  other  of  the  infectious  dis- 
eases T  thus,  of  the  one  hundred  and  twenty  cases  which 
I  analyzed  from  the  Infirmary  for  Nervous  Diseases, 
Philadelphia,  and  the  Institution  for  Feeble-Mmded 
Children,  IClwvn,  there  were  sixteen  with  this  history. 

The  anatomical  lesion  in  these  cases  is  not  known  in 
all  instances.  In  a  certain  number,  ha^miorrhage  has 
been  found ;  in  others,  thrombosis  of  the  'cerebral 
arteries,  or  of  the  meningeal  veins;  while  an  acute 
encephalitis  mav  exist.  _ 

You  will  find  an  exhaustive  consideration  of  the 
whole  question  in  the  address  by  Dr.  J.  J.  Putnam  before 
the  Third  Congress  of  American  Physicians  and  Sur- 
.reons,  Dublished  in  Vol.  III.  of  the  Tran.sactions. 
"^  1  have  recently  given  in  full  detail  our  experience 
during  the  past  six  years  of  paralysis  during  and  after 
typhoid  fever." 

Of  the  nine  instances  under  observation  hve  were 
monoplegias,  or  local  paralysis,  and  in  four  all  the 
extremitTes  were  involved— diplegia.  In  every  one 
of  these  cases  the  lesion  seems  to  have  been  a  neuritis. 
You  will  notice  that  I  have  placed  among  the  lesions 
causing  local  paralysis,  myositis.  I  have  done  so  because 
we  have  had  several  instances  in  which  the  disabilitv 
was  associated  with  great  pain  in  the  muscles,  with 
positive  swelling,  and  great  tenderness  on  pressure  as 
though  the  trouble  was  within  the  muscle  itself.  The 
two  cases  which  I  shall  first  show  you  illustrate  one  of 
the  most  serious  of  the  accidents  of  typhoid  fever. 

C\^V.l.  -Protacti'ddiiack  of  typlioid  fever ;  in  the  tent  It 
week,  zv/iile  t  lie  fever  still  /persisted,  sudden  convulsions  ;  Jtemi- 
f^lcoiiUi^'ith  aphasia. 

'Annie    F.,  aged    ;,  admitted   to   the   medical  wards 
October  3.  1S95,  complaining  of  inability  to  use  the  right 

There  is  nothing  of  note  in  the  family  history.  With 
the  exception  of  measles  at  four,  she  has  been  unusually 
strong  and  well ;  and  has  always  been  a  very  bright, 
intelligent  child. 


'i:i    ll 


■Studies  in  Typhoid  I-ever,  Johns  Hopkins  Hospital  Reports,  Vol.  V. 


f'f'-yri 'I. /■:(,•/ 


tin 


]) 


/  rx 


"'.'"^-  thu  first 


yy/'//o//)  F/aEA'. 


ity  and 


patient  1 


WL-e, 


"g  of  jj-iin 


(ipistax 


'ad  imich 


•1  A 


nia! 


had 
feve 
to  be  d 


'"•    *'"  the  6th  sh 


P'-il   of   the 
■so  with  head; 


'"   the  a!.<] 


aiu 


a   slow 
1"  ^'ontiiuiino-  f, 


"men,  fe 


'"■"^'■^'^•t^'d    attaek 
',""  "'"•■c^-  than  ten  w 


^'went  to  bed 
ver  and  diaiTh 


j""'-se/ii    \(_' 
L'lie  and  del 


bil- 


the   d 


•<^inp]ain- 
'»-'a.     Sh( 


seized  with  V  ole'   ""'''   '^""day,  J 
thehe,-w1    n,,    .^"^'-""vulsiop      u 


■eeks.     SI 


iarr]](x>a  and 


H>  seemed 


the  head,  th 
'^'he  attaek 
noon  the  m 


^  riyht 


L-aine 


UISK 

'"in  and  1( 


/\"V   .^-   when  she 


whieh  were 


Was 


"venient 


on   in   tJie 


SI 


^'xion  and  ext 


•"^  cease 


iiKjrnin 


^^  was  nn 


^'cnfined  t( 


■<1  in  tile 


^--days/^rrS7;"::'\^'-^'--nnt; 


R.  and  in   the  aft 
lead  ' 


<-'"nscioiij 


er- 


"ompletely  j 


arm  or  I 


hem 


eg. 


;^aralvze( 


"    "''ticed  that  th 


'Hit  movement' 
"■'  arm  for  nearh- 


and   she 


iplegia  th 


T 


lie   f; 


and  tl 


le  child 


e  riu-ht 


side  w; 


^'-'c  was   also 


'■tiinained 


^l^  was  total  loss  of 


wasnnable  t.;  mov 


:is 


involved.     W 


proved,   bt.t  verx- 
tirst  noticed  in  th 


4'hasie  for 


th 


th  tht 


P^^wer  of  speeeh 


slowlv 


Vol 


sion.     She  has 
has  gradually  b 


t-'  right  leg  six 


«even    weeks.     SI 
untarv  mov 


never  i 


l^^  weeks  after  th 


ements  w 


le  im- 


ere 


ained 


L'  C(;nvul 


-•-'  "^-.^aineu  power  in  fi,       -■-->^iivi 
'^'«""  to  talk  aL..!in      'm"^^?.^™'^tu  si 


'::ii:^^^'.^-^^tn,:]z^f^\''^-^^^h 


'le 


plegia,  whi(-h  li 

she  walked  into  th 
be--- 


ind 
^'•'^  partially 


ffait  charaeteristic  of'h 


reeovere 


ing  dragged,   witl 


that  she  h.,. 
the  sole  of  tl 


>^  room  that  she  1 


^'ou 


IS  now, 
emi- 


notie 


■ed  as 


IS  worn 


'    ^l-wl„;;?;ff^''^-nghtleg 
^'^vay  entirelv  h!,*^'^.:..,^""  ^<^^,  too. 


g'ots  al 


Y, 


ong  vet 


iL'  right  shoe.      Cr 


t'l'ely  the  onte 


ou  notiee   as'  I 


y  well   and 


Ppled 


as 


""  -see,  too 
r  portion  of 


en 


wh 

tended  fr 
left 


th 


«i?e  attempts  to 


j«  able  to  ni 


^^  i«.  yet  sh( 


V'^\'  this   eoin  int 


"  quite    bri; 


^n  the  sid 


pick  it   up,  th 


arm  and  side  fo 


^^^  and  semi-ile.xed 


e  1 


th 
ight 


but 


kly. 
'irena,   that 
arm  is  ex. 


l^">-^rwi;^,';r;;;!;;";;!,.-si!-^; 


•'^iie  })uts  the 


to  th 
Sh 


'■^  side,  the 


wrist  Hexed 


pose  the  right 


e  coin  with  th( 


e 


e   can    voluntarily  i\ 
can  lift    the'h; 


I  bo 


w 


ex 


and  th 


e  fin 


extension  in  th 


'"d    extend"  th 


,,'irm  is  held  elo.se 
Rcrs  also  Hexed 


'^^\^'M\iG  head,  b 


finders,  and  of^'^S"":'.^"?-,  power  Of 


'U(  th 


e  arm    at  the 


pJetely  lost.     Wh 


foi 


Jjrasping  with  the  hand 


an  object,  th( 


y  exertif 


extension  in  tl 
are  almost  eo 


power  of 


le 


side,  but  thei 


condition  of  the  f-.^ 
hrst  .saw  her  early  i 


en  niakintr  an 


'e  are  no  irreuid 


ice  ha 


Id 
'r  movement 


m- 


of  t! 
I 


bett 


le  muscle! 
11   one   other 


n  Oct 


•■^  unproved 


out  from  the 
•'^  in  it.     The 


her,  but   th 


^■er}'  much  sin 


ere   IS  still   par 


ce  we 


'esis 


er. 


<>n  notii 


;;^PecJ     too,   she  has  ,ot 


■e  now  :  hat  si 


le  can  u; 


ve'-'-  m„(,], 


iiie  olijects 


cor- 


1  I 


6  \V  11. 1. 1  AM  OSLER. 

rcctly,  recognizes  a  knife,  a  watch,  and  a  cent, but  is  con- 
fused somewhat  between  a  cent-piece  and  a  live-cent 
niece.  Her  sister  tells  us  that  in  the  inalter  of 
sneaking  the  improvement  has  been  quite  rapid  of  late, 
and,  indeed,  she  savs  a  great  many  more  words  now 
than  she  did  when  she  came  under  observation  early  in 
the  session.  She  looks  also  bright  and  intelligent,  and 
evidently  understands  what  is  said  to  her. 

Hrieily,  then,  tins  child  is  suffering  with  hemiplegia 
which  followed  a  convulsion  in  the  latter  part  of  an 
attack  of  tvphoid  fever.  vShe  is  recovering  the  power  ot 
sneech  and  the  paralysis  of  the  face  and  of  the  leg  is 
better,  but  the  arm  remains  (|uite  helpless  and  is  becom- 
ing spastic.  ,  , 

As  not  infrequently  happens,  when  one  unusual  case 
appears,  another  is  certain  to  follow,  and  I  am  able  to 
show  you  here  a  second  instance  of  hemiplegia  deve  op- 
ing during  typhoid  fever  in  a  man  who  has  just  applied 
for  admission  to  the  hospital.  .     ,r      ,       p 

C.\sK  U.—Scvcrc  attack  of  typhoid  fever  in  March,  16(^5  ; 
at  the  end  of  the  second  wck,  without  convnhwn,  slii^ht  hcmi- 

hlcvia,  which  /persists.  ■..    a  .     m 

W.  H.  B.,  aged  25,  clergyman,  was  admitted  to  the 
hospital  November  30,  complaining  of  paralysis  of  the 

left  arm  and  leg.  ,-,,.•.  ^     ,  ,,11 

His  family  historv  is  good.     Patient  was  not  at  al 

strong  as  a  child  ;  but  was  very  well  as  a  young  man  and 

whileVi""'^^ii"g  l^i'^  theological  studies. 

On   March   10,  1895,  he  went  to  bed  with  headache, 

fever,  and   diarrhea.      Gradually  all   the   features  of  a 

very   severe   attack   of   typhoid   fever   developed,  with 

much  delirium.  111 

On  I^Iarch  24th  the  paralysis  developed  suddenly 
without  convulsions.  There  was  also,  Dr  R.  k.  Kneass 
informs  me.  no  aggravati.m  of  the  delirium  follow- 
ing the  attack.  .  .  , 

He  had  no  difficulty  in  speaking,  there  was  no  trou- 
ble with  either  rectum  or  bladder.  He  had  a  very  pro- 
tracted convalescence.  Throughout  the  summer  there 
wasaoradual  improvement,  so  that  about  July  ist  he 
was  able  to  stand  and  began  to  walk.  Ihe  power  over 
the  Ic"-  muscles  has  returned  more  rapidly  than  m  those 
ofthe'"arm.  He  has  never  regained  any  power  in  the 
fniP-ers.  There  has  been  a  steady  gam  m  weight  since 
his  illness.  This  is  the  history  of  the^  ca.se  as^obamed 
i)v  Dr.  Thomas 


who  first  saw  him,  and  from  Dr.  R.  K. 


'"■'K'nal 


^e«Pect.     Tlie  left   arn   1  '",  '>'^^-^  '-»'•«  "ormal    n  e  .e,; 

aim  are  very  thi„.  ,.,,„i  t],,>   >,^';-      ^J^^'  niusc'es  r,f  the 
left  lejr  ean  br  Trv..,!  f.     ,  '"^^'"■'^■^ei  are  wasted      'n 
extended   at   ^^  ''"''^'y  ''^  ^''^  tliio-h  an     n         i     "" 

tended  sli;^-      .      '^     '^^^e  feet  ean  ^>e  S vc^f  and  T'' 
AI;n.n.entsofeversionaJ-.t"rsf;:;; 


An  interestinrr  featnn-   n   <  • 

oceurrenee  c.f  Nvide<?  {,,,!'  ,,;''^^'^f^'''le  at  first,  is  the 
'-^t  emptin^i,r  any  voluna.TeffArf-n '''['"  "^«vements    , 

ver   is   exeeedinoi\^i:are'^'F  J!f"  •''''^^'■•'^  '"  ty])h<,id   fe 

fie  fevers  it  is  very  un<?;.m  ^.^  1^!""  ''^  ^^'^' ^P^-- 
and  twenty  cases  which  for  h/  ,  ^' "-'  ""^'  'nuidred 
fT'-apli  on  the  Cerebral  Pls^s'fM"  •,'/""  '""  '"v  mono 
instanee  of  heminlcf.  f  ,  '^  ^'"''''"C".  there  was  no 
one  hundred  an d  '  S:  '^'•""^^•'"S  this  disease.  V?  th 
fotu-  only  oeeul-Jed"  ^phoid"'  ''^"'  ''''  ^^^^^'lei^be^^ 
r.d;  experienee  in  tvi^ho  d  t,^      l;^;-,    ^"  ^^  -'"ewh/u 

Dr.  Franeis'l\a^,L\  asSSr  o'   '''"'    ^^^Vl/^S^ 
he  literature.     Three  el   t'n"'f ''".^>'^''^^''^  ^^ 

er  fifteen  vears  of  aoe  hL  /    'V^-'''  '"  ^''^''^^ren  un- 

the  data  were  -iven  u'e  ti  m  f  "'■^^^"  ^''''■^^^'^  '"  ^vhich 
week  in  one  cr^se,  du  ^V'  V\hi"ri"'i  '"  ^'^^  «^^°"S 
during  the  fourth  week  in  t  J  -L  ^^'^^^^'k  m  six  cases, 
cenee    in    fi,..  ^ases      TI  "    -  o^..""- f '  '^"""- '-^""vales- 


twelve  oft 


!(■  SlXt 


een  cases  i 


.I'iftht  side  w 
whieh   th 


as  paralv^ed 


e  sid 


m 


e  was  niei 


n  t 


,.ii  i  1 


8  WILLIAM  OSIER. 

lioiu'.l.  Aphusi  .  accompanied  the  hemiplegia  in  twelve 
inslatu'cs,  Of  the  seventeen  collected  cases  only  two 
died,  and  in  both  of  these  a  thrombus  was  present  in  the 
middle  cerebral  artery.  Probably  this  is  the  usual  lesion 
in  ivplioid  fever,  and,  as  you  know,  in  this  perhaps 
more  than  in  any  other  disease,  there  is  a  tendency  to 
Ihe  formation  of' thrombi  in  the  arteries,  lindocarditis 
is  so  rare  that  hemiplegia  from  embolism  must  be 
very  uncommon." 

We  had  tliis  year  a  sad  illustration  of  the  occurrence 
of  lhrond)ous  formation  in  the  cerebral  arteries  in    ty- 
phoid fever.     The  case  is  given   in    full  in  our  recently 
issued  "Studies  .n  Typhoid  Fever,"  but  I  give  here  a 
brief  abstract  since  it' bears  directly  upon  the  question. 
The  patient  was  a  young  man,  aged  22,  of  good  fam- 
ily   hislorv,    who  was  admitted   April  24.    1S95,  on   the 
fourth  day  of  an  illness,  in  which  he  had  headache,  pam, 
and  fever.     On  admission  the  temperature  was  104",  but 
sank    on   the  ■■  dlowing  morning  to   100.7  .     l''"i"  ^^^^  f<^^- 
lowing  three  or  four  days  the   temperature  range  did 
not  reacli  the  bathing  point.  102.5°.     On  the  27th  rose- 
spots  were  seen,  and   the  spleen   was  palpable.     On  the 
morning  of  the  28th   the  temperature  was  99.3    and  m 
evening  100°,  and  he  seemed  to  be  doing  well  in  every 
respect.    At  noon  on  the  29th,  as  we  were  making  the  visit 
in  the  wards,  Dr.  Thayer  was  hurriedly  called,  and  he 
found  llie  patient  in   .some  distress,  complaining  of  un 
easv  feelings  in  the  head.     The  pupils  were  dilated,  and 
in  a  few  minutes  he   had  a  short,  sharp,  general,  clonic 
convulsion,    beginning   almost   simultaneously   in  both 
arms.     The  eyes  showed  marked  conjugate  deviation  to 
tlu   left  and  upwards,  the  head  also  being  drawn  some- 
what to  the    left.     For  about  an  hour   the    convulsions 
were  re[)eated  at   short  intervals.     Morphia  was  given 
liypodcrmicallv,    and    chloroform    administered.     They 
tlien  became  less  intense,  and  finally  cea.sed  altogether 
for  several  hours.      During    the  convulsions  there  was 
profound  unconsciousness,  and  in  the  severer  ones  great 
embarrassment  of  the  respiration,  .so   that  he   became 
(|uite  livid.     In  the  interval  the  patient  appeared  to  be 
conscious,  and  spoke  to  those  about  him,  and  seemed  to 
unc'.crstand  questions,  though  he  had  a  confused,  fright- 
ened look.     At    5    P.  M.,   the  convulsions  recurred  with 
great  severity,  and  in  spite  of  inhalations  of  chloroform. 


'"'John  Hopkins  Hospital  Reports,"  Vol.  V.,  page  465. 


liey  ivciirrcl  a,  ,„,,,,,„,  .  .  "^"'..  „ 

mmsmmB 

»f.->nce    corrotoK    ,.  •'■'to'";,:'"'-'""''  ■•>""  "'^' br  hM^' 

hate  neighborhood  of  tlKhr   •'\''''^^^^"^'^>  i"  the  im,^i 
areas  extend  sometime     for     d""'"'"'  ^'^■«''^^^'«-     l^iese 

■'^'.s,.  as  likewise    the    Svlvy'^'T  '"'''  ^'^^  ^'-^m  thrombn 

traceable  i„t,ahc  bran?  "'r,';"'  ''■■"*   "■■''""W    rae 

fenor  external   frond'rfi    '^'"V  S^-nerallv.     Thel   " 
anterior  perforated     i;^^^;^^^   f^  arteries  '^^, 

.  "On  seetion  of  thi  bAin  ti  ,  ,    '^'^  *'"'"  thrombi, 
mieal  lesions.     The  ven  rVl/  '"^^'^^  "^'  '^^oss  anato 

''ct:ituresofty;,;;::y\;:;::^----tdiiau.d^   -^- 

Kiew   Horn  different  or- 


?ans. 


There 


two',;!;i^;^"7;-iS;ty  "f  ,.0^00.  ,ecov 


gain  eompletelv  th 


1^''"'  ;^''"-  in  all  proba])iI 


en-  in  these 


power  uf  speeeh.     1 


n    both 


nty.  re- 
eases 


TO 


U/f./.lAM    OS/./'.h'. 


I 


H!l 


l!  I 


1 


there  will  be  some  additional  improvement  in  walking. 
In  the  matter  of  prognosis  in  recent  cases,  it  is  worth 
noting  that  of  fourteen  of  the  cases  collected  by  Haw- 
kins, in  which  the  result  is  given,  nine  recovered  com- 

])lctelv.  ,  •     ^1      i-       ^„ 

These  upper  motor  segment  paralyses  m  the  fevers 
are  fortunately  exceptional  and  rare.  In  a  much  larger 
series  of  cases  the  lower  motor  segment  is  involved  and 
the  picture  is  of  a  spinal  or  neuntic  paral>  iS.  1  he 
lesion  may  be  either  central,  involving  the  grey  matter 
of  the  cord  to  a  greater  or  less  extent,  or  peripheral, 
involving  the  nerves  oi  the  extremities,  more  rarely 
those  of  Uie  eve  and  of  the  palate.  _ 

Gowers  states  that    anterior  \w\\o  myelitis   is  more 
frequently  secondarv  to  typhoid  fever  than  to  any  other 
acute  specific  disease,  adding,  however,  that  when  the 
onset  is  subacute   the  symptoms  are   no  doubt    due  in 
many  cases  to  a  multiple  neuritis.      I  he  very  full  report 
.riven  by  Bury  of  cases  of  paralysis  following  typhoid 
fever   U"  the  monograph   by    Ross  and  Bury  on  peri- 
pheral neuritis),  does  not,  however,  bear  out  this  state- 
ment     In  a  great  majority  of  all  the  cases  there  noted 
the  condition  had  been  evidently  a  peripheral  neuritis. 
It  is  stated  that  some  cases  have  presented  the  picture 
of  an  acute  a,sccnding  paralysis,  and  death  has  followed 
in  a  few  days ;  but  it  may  be  that  even  in  these  instances 
with  the  type  of  Landry's  paralysis  the  lesion  is  a  peri- 
pheral  neuritis.     The    two  cases  of  ascending  myelitis 
described     by    Raymond    (Revue   de    Medicine,     1S85), 
both  of  which  showed  marked  changes  in  sensation,  as 
well  as  progressive  muscular  debility,  and  which  recov- 
ered rapidly,  would  nowadays  certainly    be  regarded  as 
neuriti.s      There  is  less  doubt    about    certain   cases  of 
monoplegia   and   of   local  paralysis;  as  m  the  case  re- 
ported    bv    Shore    (St.   Bartholomews    Hospital     Re- 
ports  Vol.'xxiii),  in  which  there  was  acute  myelitis  of  the 
antei-ior  cornua  from   the   third  to  the  eighth  cervical 

nerves.  .  ^     ,  4.1  ■„  i 

For  the  purpose  of  comparison  I  show  you  a  tuiia 
case  illustrating  the  neuritic  form  of  paralysis  m 
typhoid  fever.  From  his  general  appearance  you  can 
easily  see  that  this  patient  has  been  through  a  severe 
ordeal  He  has  been  in  the  private  ward  for  exactly 
two  months,  and  is  now,  as  he  would  express  it,  as  long 
and  lank  and  brown  as  the  Ancient  Manner.  He  is, 
however,     convalescent,   and    has    consented    to   come 


II 


Wore  ,o„  .„.,„,  „^;;-'"™'- --"«■.       „ 

I  Will  first  reid  .-        ,•  "^'^-^"^ed  us  great 

abdomen.     "=  -"■^  "-'  ••■  «o„l  ^eafof  Sn^V,'iU;;  ',;";,:I^ 
.'-'n  admission     fh^  f     .  '"  uit 

quite  well  marked  ^n,/^^^"'-es   of  typhoid    fever 

elbow  or  shoulder, o?  of f^f '"'"'•  ^"<l  P-'s^ure  on  lie 
next  two  o.^T''-"  ^^'•'■'-'  ""mb'a";-  ^tiff'  ^'-P'ained, 
On  the  34th  of  sZ7^r%™"K''''f™ni98"lomT 

al's^  i^r-"'^ :?  «--"-^tl;efoi;;t"o74tt"'£ 


-     -w^^     aiin.       h 

gi-asped,  but  there 


was  no  special  tender 


■fn   the   humerus 


was 
ness  over  the 


12 


WILLIAM  OSLER. 


i '  I' 


<ii 


I    ' 


'"  ( );f  tirSli"  he  paiS^;- -O-  much  less.  He  could 
neilhe'mtC^'^lIt  arm  fron.  the^^nUder  p,nt  m,r 
llox  on  extend  it  at  the  elbow.  Iheie  us  compete 
vdst  drop,  and  he  co^.ld  only  Just  move  the  fingers.  1  he 
eos  c  uld  not  be  drawn  up,  nor  could  he  move  the  toes 
Ziither  foot.  The  mt,scles  were  ilabby  jn^l  greatly 
wasted  from  the  fever,  but  they  were  ."^^^  tcndei 

There  was  slight  improvement  m  the  paiaV-cd 
limb  He  c-ould  move  the  hand  and  forearm  and  the 
u  rist  cou hi  be  slightly  extended.  The  grasp,  however 
^a'^eatlldy  Veri^ept^ble.     There  was  still  deep-seated 

^^"it"2^tr^;!r:^  not  lift  either  leg  f;.m  the 

along   the  nerves;  no  para^sthesia  ;    the  .sensation  was 

""'oSober  .0  the  note  was  :  "He  cannot  extend  the 
fin^rers  He  can  flex  the  arm  at  the  elbow,  but  it  tails 
ovS  at  once  The  left  hand  and  arm  are  not  and  have 
not  bfen  alfected.  He  can  draw  up  the  legs  slightly  at 
the  bins      There  is  still  complete  foot  drop. 

Du  ngthe  last  few  days  he  has  in^P^oved  ve ly 
rinidlv  He  can  extend  the  hand  and  move  all  the 
in^c  'but  Uie  grasp  is  very  feeble.  The  egs  can  be 
rwn  up  at  the  hips  and  flexed  at  the  knee,  th-  ugh  there 
fssiZJe  evident  bilateral  foot  drop  He  can,  how- 
evet  mTve  the  toes  a  little.  The  rapid  improvement 
tv^:?hin  the  past  few  days  is  a  very  favorable  omen  m  the 

''''"The  distribution  of  the  paralysis  in  this  patient  is 
quite  uisial.  In  the  paper  already  referred  to,  vou 
uMl  finirfull  details  of  the  nine  cases  of  neuritis  during 
and  afer  typhoid  fever,  which  have  been  under  obserya- 
ion  n  the  hospital  during  the  past  .six  years.  1  e 
niosis  is  usuallv  good,  and  in  the  case  before  you  the 
Imirrovementof  the  past  ten  days  has  been  .so  maiked 
that  probably  his  recovery  will  be  rapid. 

nVith  systematic  friction  to  the  arm  and  legs  the  power  returned 
within  a  few  weeks. 


/>^v^.,,v,..    ,,,    ,^,^    ^^^._^^^^^ 


001 


M'ifli  .losos  of  fVon,  ]  ,„  .,  , 

::;^ V"'"v''"" '•■-'•■-'  .t:'?'''r'r''''' '''^^■•'-'^- 

'  "  '•     if  .■or.a.nly  |„s  ,,0  ..,11.,   ,„„  '     '   '^  ^'""■*;"^^l'Iy  ^"ti.-^fa.torv  ,,„.  |„. 
;•     7' '"'  '■'"•••^   "I .1...  .In..|.  .i  .     "  '■-^•'••'•ilitv  of  tlH.  I.^„.,,. 

;;:  ^:'  ;;■ " ;''- «--. . ,.",";,::' ;;', '"-  -" :.  .1....: 

™"-."»™h,  :;:;,.;;■'■'■ "; '"'■-^■""'.:r",;;t"":": 

::'■■""' '^^-  ^"'; '":;:"  r,,;;!:;'^-  '"7;  -«-'""^..  i :;:;;:; 

^-'<-.  of:     8o,no  patio,,,.  :.,.„.  ,/t^.3^^'  ^'l':'"^  '""-  "  ^lay,  J,.s  b.,„„  , 

-,  o„s  a,.t,..ities.     Tl.,.,,,  oM:;      ,::':;;;;;  '■-  '-->  .•ooon„„on,K,.M,' 

''^^N'b   ao:a„,st  ,t.     A,  :tl,„  sa,„o,i„,  ,    '"'    ""'    ''<■  w-Vhod    vo,-v' 

pa  ie.u  ,s  a  chu,.o,- that  .houl.l  t  Zl     l'  '""''"'"  •^^' ""  "l'-"'-ont..,.      '^ 
r;'':    --•     "-v..v,.,vas  I  haCe         ,';:v""^'^':"'''^'--  ^■^P«-Hy  h.  i.    i^ 

^^«•l-8a„  a„tho,-ity  tha.,  r.a,,.e„ll^^  1  ^  "      "'  ^'"  ""•*'  »^"  a»ou,-i.s,„ 

-•!■  treatjne,.,.     The  sy,..pto,  a  ,         :'  ^"  '''\ '— '  '--ofit  ii. m 

"'f  J?ene,-al  co„ditio„  of  the  natie,,  '""■^'   ''^'  "^"'^''-l  "speeiallv  to 

'•'""^^vhioh  oan  be  .x^hY-Ved  h  .^""''''"^''^'"'''^  (''••^''''1^  tuber  ,,] 

;  -^-      Who,,  the  he,;,o.^.a,e  ^      :  :  t"  '    ""  •  "f '  "^^"'^'  -"'  ^  '-"- 

^^  «ac  „,to  a  bro,.ehial  tube,  tl,e       4   ^ '  "  '"  ''"  '""J"""'"  "^  -'  ""eu- 

'-ires,  dcpe„diu,  upou  lesious  of  b  o    ^      ^  '  T  '?r"""     '"''^"^  '-»-- 

-«;"i>ns  fo  tl,e  rules  ostablisl,ed  i\,Z       T  '^       '    ""'  '""•^^'  '""'^^  ^o  Seated 

T"  '■IosI„.-r  t],is  el,aVter  I   •.  '  ,f' """^  "^  J.<.,„orrha,.e. 

•'"•  present  ti,i,e 


|">iitaiieoi,,« 


cure  have  I 


cases  „f  euro   have  Ik 


«''•"  a  ease  of  tl 


'<'(•»  ob,scrvcd,  I  am  t 


■ei. 


a  very 
■^'poi'tol,  and  eases  of 


:iii< 


'"i-aeie  aueurisu,  vuivd.    I  \t; 


I'w  to  confess  that    I   | 


ave  „ever 


;'-'  \  ff-.k,  i^eon  able  to  prolo.ig  mlTi^::'''''':^'''''  ""'•''^^■-'' 

^      '  ^"^  ^  '"^^^'  "«t  obseiTod  auything 


approximating  a  cur# 


n 


C  /--  X  X 


■.I  :!   ^ 


fj  I 


DISEASES  OF  THE  BLOOD  AND  THE  DUCTLESS 

(;lands. 

liY  WILLI a:m  oslkr. 


The  Anemias. 
THKORF.TICAM-Y  tlic  iuifiuias  (lopt'iid  upon  oitlicr  iiuTOJiscd  ronsiiinptinn 
or  .liminislicd  prodiicticm  of  the  l)loo(U'lcinents,  {■onned  or  imformcl ;  l.ut  it  is 
pra(!ti<'iUlv  impossible  to  niako  a  division  of  the  eases  into  those  with  increased 
henioivsis  and  those  with  defeetive  heinoKcnosis.  Not  infrequently  thi>  two 
conditions  coexist.  Of  the  patholofiv  of  certain  ..f  the  more  important  forms 
of  anemia  we  are  still  iKii<»nint.  For  the  purposes  of  this  section  I  shall 
consider— (1)  Anemia  ironi  hemorrhage;  (2)  The  secondary  or  symptomatic 
anemias;  and  (.3)  The  primary  or  essential  anemias. 

1.   AnKMIA    IMtOM    TlKMOIUUIArrE. 

Small  hemorrhages,  such  as  an  occasional  bleeding  from  the  nose,  make  n.. 
impression  whatever  on  the  general  conditicm.  Frecpiently  repeated,  howevci-. 
they  may  lead  to  very  prononneed  anemia,  as,  for  example,  in  eases  of  nterinr 
niyomata,  or  of  hemorrhoids,  or  of  aid<ylostomiasis. 

'  Acute  anemia  follows  loss  of  large  aiiioiints  of  blood,  as  in  hemorrhag( 
from  wounds  or  erosions  of  arteries,  in  post-partum  bleeding,  and  in  the 
so-called  spontaneous  hemorrhages  in  subjects  of  the  hemorrhagic  diathesis. 
When  the  bleeding  takes  place  (piickly  and  in  large  volume  there  is  a  true 
oligemia.  The  amount  that  may  prove  fatal  depends  a  good  deal  upon  tiic 
rapidity  with  which  the  blood  is  shed.  A  person  may  lose  in  acute  henioi  • 
rhage,  without  dying,  so  it  is  said,  at  least  a  third  of  the  blood-volume.  Tlw 
largest  amounts  that  I  have  known  were  seven  and  a  half  pounds  of  blood, 
which  escaped  into  the  pU'tn-a  from  rupture  of  an  aneurism,  while  in  a  ca-i: 
of  cirrhosis  of  the  liver,  in  a  ])atient  of  Dr.  George  Ross,  ten  pounds  of  blo..d 
(by  measurement)  were  lost  within  a  week,  without  a  fatal  result. 

In  actite  anemia  the  chief  danger  is  the  lowering  of  the  blood-pressure 
to  a  point  at  which  it  is  impossible  to  maintain  the  circulation;  less  serimi- 
risks  are  hemorrhage  into  other  parts  (as  in  the  brain,  instances  of  which  have 
been  known  to  occur  during  venesection,  and  during,  hemorrhage  from  a  round 


deer)  and  the  occurrence  of  paraplegia  or  a  neuro-retniitis. 

if  interest  is.  How  low  may  the  Idood-count  sink  after  lu 


A  (|uestion  o 
r'lage  and  yet  the  patient  recovei 


In  a  case  of  hemorrhage  from  a  duoii 


nii'i'- 
cn;il 


nicer  the  blood-count  said<  to  740,400  red  corpuscles  per  c.mm.     The  patimt 


y(ia 


JCTLE8H 


(•(insiiniptidii 
nod  ;  Itiit  it  is 
A'itli  increased 
cntly  (lie  two 
poi'tant  t'ornis 
3i'tion  I  sliall 
•  symptomatic 


nose,  make  mi 
att'd,  however. 
ascs  of  uterine 

11  liemorrha<;e 
g,  and  in  the 
laujie  diatlu'.sis. 
hero  is  a  true 
deal  upon  tln' 

acute  henioi 
■vohinie.  The 
niids  of  bhiod, 
\vhile  in  a  ea-i; 
Minds  of  blond 
t. 

blood-pressure 
n  ;  less  serious 
of  which  have 
0  from  a  rouml 


ik  after  hennn- 
rom  a  duodiiml 
.     The  pati.iit 


m 


aof 


iKi.  ;i2,-rh 

tlifpriK 
less  cdrj 


-•••■ond,  t( 

lavor  in  ( 

It  is  ii 

luiiiorrJia 


J>isi:asi:s  oi 


'Hi:  Jii.iKi 


/>    .\.\f>    '/•///,; 


'""'   ''l''l   f'..r  (vv.mIj, 


IXrTl.Lss  (ti..x  V 


vs  and  on  udn 


/'.v.    !)()({ 


"^^'""   I"  111.'    lln-,,i,,.,I 


""•  ""iK'ali.ms  ill  ;uK,,,|.MV       1  '"'  •■••^"""i"n. 

"'""""'"■' ••■''■•'^-■•"v.fi.s,,  „...,.„„,,  „,,.,.     , 

____^  '  '"IK    NIC   li|(.,.(||,|,r  . 


"!<►?    0,(KKl,l»Kl 


Mf 


oml,  to  replace,  it 


ivor  m  cvtTv  way  l.l,„„l-f 


,  It  nece.«sa,y,  tlio  voliuiic  of 


It 


IK'IIIOIT, 


i«  iinpo,ssibIe  t„  .<j„.alc   j 
'lago  (they  ilej,eiicl 


oi'iiiatioi). 


fimilatiug  il„i«J ;  and  third 


to 


'<■«'  of  all  the 


measures  employed  for  dieck 


«omueh  upon  the  situation  of  the  bleed 


uitr 


ng  vessels), 


WSlSlSHgKUmM 


i\ 


1 


904         AX   AMERICAN    TEXT-BOOK    OF    THERAPEUTICS. 

but  it  may  he  said  in  gciuTal  that  absoluto  rest  in  the  recumbont  posture,  with 
the  head  h)\v,  the  loeal  application  of  cold,  and  the  adininistratiou  of  opium 
are  perliaps  tlie  most  important.  The  dangerous  liemorrhages  of  pubnonary 
tuberculosis,  jiastric  ulcer,  and  typhoid  fever  result  from  erosions  of  vessels — 
lesions  little  if  at  all  iuHuenced  by  the  various  medicinal  remedies  employed 
in  such  cases.  Under  tiie  appropriate  sections  will  be  found  fully  discussed 
the  indications  in  the  various  forms  of  hemorrhage. 

Here,  however,  may  be  considered  means  to  be  adopted  to  meet  the  second 
indication— namely,  to  re|)lace  as  (piickly  as  possible  some  of  the  circulating 
fluid  that  has  been  lost.  When  collapse  seems  imminent  in  the  sequence  of 
a  profuse  hemorrhage,  what  is  known  as  auto-transfusion  may  be  practised, 
by  applying  Esmarch's  bandages  to  the  extremities.  Sufficient  blood  for  the 
heart  and  brain  may  in  this  way  be  furnished.  If  this  does  not  suffice,  arti- 
ficial transfusion  must  be  practised,  for  which  purpose  the  defibrinated  blood 
of  a  hcalthv  individual  is  to  l)e  employed.  From  200  to  300  c.cni.  may  be 
injected  without  any  risk.  The  transfusion  may  be  followed  i)y  a  chill,  which 
is  not  usuidly  of  serious  import.  Von  Ziemssen's  method  of  transfusion  is 
on(>  likely  to  come  into  gen<>ral  use.  Two  or  three  well-made  glass  syringes, 
of  a  capacity  of  20  or  25  c.cm.  each,  are  provided  with  sharp  hypodermic 
needles,  united  by  a  short  piece  of  rubber  tubing.  The  instruments  must  all 
be  carcfnllv  sterilized,  and  tlie  skin  of  the  arm  of  both  the  giver  and  the 
receiver  of  the  blood  properly  disinfected.  A  couple  of  assistants  arc  neces- 
sary, and  a  snj)ply  of  hot  sterilized  water  and  hot  sterilized  salt-solution.  The 
.svrino-cs  and  needles  are  kept  in  the  liot  sterilized  salt-solution.  The  blood 
is  drawn  with  a  syringe  directly  from  the  median  vein  of  the  givor,  without 
anv  preliminary  incision.  It  is  usually  ncfcessary  to  apply  a  bandage  on  the 
upper  arm  in  order  to  get  the  vein  sufficiently  distended.  AVhen  the  syringe 
is  nearly  full  an  assistant  inserts  a  needle  into  the  median  vein  of  the  receiver, 
and  the  blood  withdrawn  from  the  giver  is  injected  directly  through  thr 
needle.  With  instruments  in  proper  order  am'  everything  prepared  systemat- 
ically there  is  very  little  risk  of  the  blood  clotting;  and  Von  Ziemsscn  s;iy- 
that  from  200  to  300  c.cm.  of  blood  can  1  .  injected  in  tiiis  way  in  the  cour.-i' 
of  fifteen  minutes.  If  for  any  reason  it  should  be  thought  advisable  not  tn 
transfuse  into  the  vein  directly,  lo  or  20  c.cm.  of  blood,  withdrawn  in  the 
way  described,  may  be  injected  subcutaneously. 

A  means  that  has  supplanted  in  great  measure  the  transfusion  of  blood 
is  the  use  of  sterilized  saline  solutions.  The  tcehn>('  is  very  simple :  Th" 
warm  .solution  is  poured  cipher  into  a  funnel  or  into  the  bag  of  a  foiintaiii- 
svringc,  i)rovided  M'ith  rubber  tubing  of  jnoper  length,  to  which  is  atta<liii| 
an  aspirator  needle.  The  needle  is  inserted  beneath  the  skin  of  the  flank,  ;'.iiil 
from  a  pint  to  two  ])iiiN  (500.  to  1000.)  of  the  fluid  allowed  to  run  in  slowly. 
j'.v  means  of  gentle  massai>-e  the  fluid  can  be  rcadilv  dill'tised  Ijencath  the  ,-kiii. 


if 


m!ccssar\' 


the  salt-solution  mav  I)c  dircctlv  infused  into  a  vein.     The  nm-t 


common  solution  is  the  common  sterilized  salt-solution  of  0.75  jier  cent. 


foil 


owing;   .solution 


has   been   iiukIi    used    i'or  the  subcutaneous   infusion  in 


rics. 

postiuv,  with 
ion  lA'  opium 
)t'  pulmoiiarv 
)  of  vos.st'ls — 
ies  omj)loy('(l 
jlly  discussed 

H't  the  second 
10  circuliUinii 
e  sequeuce  of 

be  practised, 
blood  for  tlie 
t  sutliee,  urti- 
rinated  blood 
c.cm.  may  be 
a  chill,  wliii'li 
transfusion  i.- 
lass  syring(!s, 
)  hypodennir 
cuts  nuist  all 
^ivcr  and  the 
its  arc  ueccs- 
olution.  The 
1.  The  blo.Ml 
fiver,  without 
ndage  on  the 
n  the  syringe 
f  the  receiver, 

through  till' 
ired  systemat- 
/^iemsscn  say- 

in  the  course 
i>-isablc  not  fn 
.drawn  iu  the 


ision  of  bloiiil 
simple :  The 
jf  a  fonntain- 
:'h  is  attached 
the  tlaids,  I'.iid 
rim  in  slowly. 
icalh  the  .-kill. 
n.  The  iiii-t 
K'r  cent.  Tlie 
IS    infusion   in 


i'l 


AVI  I 


Slip, 

and 

stai'v 

J>arti 

Stollli 

iiiaiii 


red  IK 
iiiiiiil 


'Irani 
clironi 


('■) 


prof; 
bers  ( 
(•f  tl 


m 


111  a  ^v< 
t  if  "lis,  ,■; 
fev 


eis 


liiit,  as  1 
■"^ypliili.. 
'•"th  the 
fi'atii 


ro. 


Of  tl 

iiiul  in  c 
liowover, 
i'<'si.st.s  trc 
iiii  iiishiiii 
aiii'iiiia  as 
IS  Mot  Ilea 

111  all 

;'i'<'iiiia  tJi; 


J>ISh\USE^    or    yy^/. 


nuM>D  Ay„  Tin,' 


l^ViTLKss  a 


•■'7'"'-     '"■-.".■.I    » ,,„»,„.        ,  '"^«  ^''..I.VAV.    WS 

"■'■"  "■'■•».  ™<i  r".»-h  1  :  r"''  '"■"  ""■  "■'■-■ » i.r,  T;";'  "•  '"'■•"■  ■■" 

'•y>^[ -•  -''- ,;;;:';;";;;:  ;'■'.■■■'';  '«■  i.>-.i .. ,; , ,  :  ;;,, ";■ 

"•ill  I.,.  „„,i,„|  i„  ,i„,  ,,     .  '"'  l"-l'a.v,ii.„„  „)■  i,,,„    „/-'"'•  "  li'«  "" a 

•>    v.. 

-•       0|-.(    (  )\  1,    1    I,,.  4 

(")  Anemia  fro.«  inanitio  '""•"^- 

.'■ 'V  ;  ■■;■'■""■'"•'"'  "■'"'  »"-i.i"     ::"'  '"  •■'"■"""■■I.-I..1.A..S 

boi-s  of  tl,,o„,,,„,,,|,,        .  "'  ""=.  '>'»<  <'Itl..T  ,l<.s,„,W„„  ,.,„;:■    """""" 

:■'■ ""» '>•■- <» ..-o.:;.;  ":."■;::,"■;■"■  i-i"--.. ■  ii.  ?. ;;;?;;;:'»- 

"'  "  ""k  <»■  ove„  lo,,  „„„;„  „';'■''"  •"  "« *,.  .!.<.  .*■„„  of,"-'""' 

-^:r::tt*;;,;:;--:;n::r;;f,::tr~ 

"f*"'"'"  °f  l«ul-,,„c™«  in  „,,„,,        ""'7    ""''  ""■"•      '  ''»"  .."■.'      ; 


'  II  all  vii>iv 
'""■'1  tJiat  aro  of 


"'o  t'oiiiinoii. 
'S  of  sown 


y'n.otoinatic  aiienila  t\ 


'"■'  "»''•«•>">•,  or  i.]>o..,,I,oras 


""''*'''^''"<^^N  ^"••ii  as  b,eathl, 


'•'■'•'  •"•^'  feit'MVs    oth,,,  tl 


le«"^^N  jmlpitation  of  the  j 


laii  t] 


le 


loart 


i^ 


M 


11 


i  I 


til 

I 


;i 


im         AX   AMERICAN   TEXT-BOOK   OF    TIIERAPEUTJCS. 

on  .■xorti.m,  tet'lin-.s  of  vorlig..  ..r  faintnehs  nmisoa,  somotimos  vomiting, -r 
prulunH  and  tr„nl,leson...  .iyspepsia.  Small  traces  of  albumin  m  tho  urun, 
and  a  tew  tube-easts,  arc  almost  •■oi.Mant  aoonipanimente  of  anemia  ot  ■•^■•n 
niclimn  grade,  and  slight  fever  is  n..t  at  all  uncommon.  _ 

Treatment  of  the  Secondary  Anemias.— In  every  cas.  it  is  most  import- 
•uit  to  <eek  for  the  cans.',  as  ui.on  this  may  depend  the  .succt-..  r.f  the  treatment. 
Thus  it  is  quite  useless  in  a  case  .)f  chronic  plmuoism  to  ,m.  mpt  to  cure  the 
anemia  without  first  taking  measures  to  seciu-e  the  elimination  ot  the  lead  and 
to  prevent  additional  poisoning.  In  many  seeoiul-;ry  anemi:t.  tlvs  cause  is 
hevond  control,  as  in  inalignant  disea-e.  _  _ 

'  In  no  group  of  cases  is  ilu.  beneficial  eliect  of  an  open-air  life  more  sinking 
than  in  many  of  the  symptoaiatic  anemias.     In  a  <'ase  of  anemia  associated 
with  protracted  .  nipvema,  after  rh.  r-moval  ul  the  j.us,  a  stay  ot  a  few  weeks 
at  the  seaside  or  in  the  mountu..>^   I'ving  in  tlte  open  air,  with  good  foo.l,  will 
ranidlv  brin-  about  a  norn.al  h]M,<^conditi<.n.     The  same  good  residts  are  seen 
in  the'anemkt  fbllowiug  prohmged  lactation.     Even  in  cities  very  nntch  can 
be  done.     Instead  of  remaining  in  a  close  room  all  day,  the  window  shoul    be 
.pen  and  the  patient  suitably  covered,  or  when  possible  the  patient  shou.l  be 
xvl-.eelcl  ui.on  a  balc(»ny.     In  eases  of  chronic  illness  there  is  still  too  mn<l. 
drc'  ,!  of  open  windows.'    Anemic  patients  feel  the  cold  very  much  and  reqm.v 
to  be  vnrmly  clothed.     In  very  many  cases,  particularly  in  women,  when  the 
cau^e  i-  ohsetirc,  it  is  often  best  to  begin  with  a  modified  Weir-Mitehell  treat- 
ment   The  value  of  rest  in  bed  has  been  emphasized  of  late  by  several  writers, 
an.l  I  .'an  bear  testimony  to  its  worth.     With  rest  may  be  combined  massage, 
the  value  of  which  in  stimulating  blood-formaticm  has  long  been  known,  and 
which  would  appear  from  the  observations  of  J.  K.  Mitchell  to  be  of  very 
srecial  service  in  promoting  blood-distribution.     The  importance  of  massage 
in  conjunction  with  hydrotherapy  in  anemia  has  been  demonstrated  by  Dr. 
Mary  Putnam-Jacobi,  and  there  is  no  question  that  the  combination  of  thrs. 
two 'methods  is  of  very  great  value  in  stimulating  the  changes  that  lead  to 

blood-formation. 

The  diet  should  consist  of  easily  digested  articles,  and  should  be  varied  and 
rcmlated  a  good  deal  by  the  appetite  and  the  tastes  ..f  the  patient.  It  is  ,.,.- 
p.u-tant  to  remember  that  digestion  is  almost  always  fl^eble  in  cases  of  anem.a, 

and  the  patient  is  better  with  four  or  five  small  meals  than  ^vith  two  oi r 

laroe  ones  in  the  day.     Very  anemic  patients  do  not,  as  a  rule,  bear  an 
sivelymilk  diet,  and  in  any  case  \v  which  the  Weir-Mitchell  method       ... 
indicated  this  part  of  the  treatment     .,ay  be  modified.     A  diet  i    ,'  :  -     -I'm- 
iniuous  elements  is  usually  bette.    U..>e  than  one  in  which  the  o.  oohjor.t.s 
and  fats  predominate.     Tea  and  coffee  should  be  used  in  moderation.        ncimc 


11.  a- 


a  ru 


le.  without  stimulants  of  any  kind.     Whei 


j)atients  do  we 

th<i  stomach,  good  porter  is  advantageous  in  tlie  anemia 

from  fevers 


jf  the  eonvali 


In  many  cases  hygienic 


and  dietetic  measures  suffice  to  restore  a  n. 


iiiUi 


condition  o 


f  the  blocid.     The  bitter  tonics  may  be  used  to  stimulate  dige.-t 


loll, 


res. 

vomiting,  fir 
11  tiie  urii"', 
mil  ol"   A'-ti 

nost  iinport- 
le  treatment, 
t  to  cure  tiic 
tlx^  lead  iiiid 
tlv  caiiHC  is 

non'  .striking 
ia  as.so(Mat('(l 
a  tew  weeks 
lod  food,  will 
suits  are  seen 
ry  much  can 
ow  shot! !  I  l)e 
snt  should  b(! 
till  too  mncli 
li  and  requiic 
en,  when  the 
litehcU  treat- 
;veral  writers, 
ned  massau'c, 
I  known,  and 
o  be  of  VI  iv 
;e  of  massage 
trated  by  J)r. 
at  ion  of  tin  so 
i  that  lead  to 


bo  varied  nml 
■nt.  It  is  iiii- 
ses  of  aneniiii, 
I  two  or  ^iiii'p 
bear  an  .a.-hi- 
method  m  ii. 
1!  h  '■■..  iliii- 
cai'boh\<\!;itcs 
tion.      *  neiiiio 

nie."    ijt'Ml"  liv 

convah      i ' ■ 


store  a  iii'^nai 
date  dige>limi, 


!:■ 


ft 


"I 


gWJHPjmuM.ii 


i  1 4 


I 


n>r.,f,.         I  ''    ■^"''  ''!<■  iiiiJdc.r  1...,,         .  '^     " '"  '"f"  }.">0(1  form.      It 

,«""•"■■■'  p"Tn.l,;r  ';;,;'■,';::  "'■'" '•»  pi"-  (-'" ,  ^o  ',;'"'t';:i - 

""'  iiatiinil  iron-water 

;;7-t  part  to  „.e  n.!;,o  .,'        '        j"' ."r  "^'-^  '-«'!  cm."  ^ 

'-■•'-'•e  aoici,  and  tlu-  vain,  o/   .n     .,    ""    '■   "  ''"''''-  ••'""^-'  -ith  f  !^ 

-.ne  of  tins  carbonic  an-d  is  noJ    n     I    /^^";"/''-"  "-^'to.'s  arc  o.vportoc 

"<■  l-ottld   waters  to  a  .leposi     „  ^  ■  ^,^^^' ""' ^'"^  -  a  ,reat  tende  cv  „ 

:'"^'-ac'ts  greatly  in.,,  the  valne  o    in  ,!"'""  '"  ^''^  ^-•"'  '^^^  oxid,  mIuV 

"•""  :^  -ally  present  a.  C^,!^';^'^'  ^^"^^^  ^'^  ^''-'  -uree.''     The 

""-  ""1-ant  iron-spas  are  8ei.  .Jd  t,  ^    ^l,;;;;^'  ^^^  P-l-tions.     Th:  ,. 

.    r,        ,.  '  ^' ''^'^"^^-""'  I^'nonl,  i.,  Europe. 

'*•   iHi-:  Prim  \i{v  ^t.  i^ 

'""•',  'ZZou  will*:;':;;:;;:!'  «;7;''*  -  -...^  fe,„„„  ,„„ ,, .   # 

<»l'«lcs.  ,      '"""i"ll«-'l«Lioglol,i„oftl,-  imlivi.iuai 


«   I 


I 


{»()8 


A  A-  ami:ri(.\.\  Ti:xr-in   >u 


njt'    TUMUAI'ErTK  'S. 


hi: 


Wliile  tlie  twsciitial  <iinsf  of  cIiImicms  i.t  imkin.vvii    tin'  iiitiiiiiit.'  ivlatioii  l)c- 
twcfii  it  and  tlu;  evoliitii.n  of  tlif  >'  \iial  functions  is  shown  by  its  onset  in  joun^r 
fbnialos  Ixtwccn  tlic  aj^rs  of  fomtmi  and  twenty.     Tlio  atUction  is  rare  ia 
males.     Hereditary  intlnenees  are  met  with  in  a  few  cases,  and  it  is  stated  tiiat 
(he  ehihh-en  of  llnnilies  in  wliieii  tnbereulosis  is  preval-vl      •     ,     ve  likely  to 
lurome  elilorotie.     The  disease  is  most  common  in  cit\-l)red  girLs,  particularly 
in  those  wh.>  live  sedentary  lives,  and  whose  work  or  position  doew  not  enable 
them  to  have  |>lenty  of  out-of-door  exercise.      In  dispensary  practice  the  eases 
are  most  numerous  in  se^nn^'-girls  and   factory-operatives,  who  work  in  cl()>e, 
ill-ventilated,  hadlv  litrl  led  rooms,  who  hav.'  long  hours,  and  wIk.sc  diet  is  in- 
suilicient  and  imperlecily  prepared.     The  disease,  however,  is  common  enough 
in  well-to-do  families.   "  There  is  a  dost;  relationship  between  tiie  disease  and 
menstrual  disturbance.      It  often  occurs  early  in  girls  in  whom  the  menses  have 
a|)peared  prematurely.     Other  cases  are  associated  with  a  late  development  of 
pubertv.     Scanty  menstruation  or  total  amenorrhea  is  the  most  constant  eon- 
comiUuit.     Cases  with  menorrhagia  are  nmch  le.s.s  freque  it.     Blonds  are  more 
commonly  the  subject  of  the  disease  than  brunets.     From  the  frequeni  associa- 
tion of  dyspepsia"  and   constipation  with  the  disease,  an   inti -tinai  origin  has 
been  sought,  and  >n-  Andrew  v  lark   particularly  has  advocated  the  view  that 
it  results  from  the  absori)tion  of  toxic  products  from  the  bowel---a  copremia. 
Ill  this  country  Forchheimer  has  strongly  advocated  the  same  view.     On  the 
other  hand,  a  primary  nervous  ori>:in   is  claimed   by  some  writers,  \s ho  base 
their  opinion  upon  the  development  of  the  di-'iise  after  a  sudden  shock  or  a 
violent  emotion,  such  as  disappointment  in  love  ;  and  (li    nervous  factor  is  one 
that  has  often  to  be  tJiken  into  acc(  >  'it.     In  (crtain  i    -tances  the  entire  vas- 
cular  system  has  been  found  abiiorm,.!ly  small  (a  condition  that  N'irchow  ha> 
described  as  liypoi)lasia),  with  imperfect  development  of  the  generative  organs. 
The  symptoms  of  the  disease  are  th-.'s^'  ;)f  anemia,  with  one  or  two  addi- 
tional features,  of  which  the  retention  of  the  panniculus  an<l  the  yellow-grecu 
color  of  the  skin  are  the  most  important. 

In  many  eases  the  disease  is  (piite  transitory,  lasting  ..ily  a  few  montli-, 
yielding  readily  to  treatment,  and  never  recurrini  In  other  instances  there 
is  a  tendency  to  fre(pient  relapse,  so  that  writers  •  -     'ken  of  a  relaj* 

form.  The  recuircnce  may  be  within  a  few  moi,  s,  oi  lay  be  deferred  tor 
several  years  So  common,  however,  is  this  tendency  that  it  is  always  well  • 
warn  the  patient  or  her  mother  of  this  feature. 

There  is  a  condition  met  with  in  women,  and  not  unknown  also  in  men,  in 
which  anemia  of  a  chlorotic  type  persists  for  many  years.  The  patients  t.-l 
well  and  are  al)le  to  attend  to  the  every-day  occupations  of  life,  but  there  i~  ;i 
constant  pallor.  On  examination  of  the  blood  the  most  striking  feature  is  n- 
impuveri-'hment  in  hemoglobii.      These  cases,  too.  are  very  resistant  to  trcni- 

ment. 

The  following  brief  statement,  with  the  accompanying  charts  (Figs.  ;3;5, :]!), 
illustrates  the  main  features:  The  red  globules  may  be  present  in  normal  luiin- 
bers,  although  in  all  severe  cases  there  is  a  considerable  oligocythemia,     lu 


cs. 


relation  Iks 
ct  ill  yniin^r 
I  is  riiri-  ill 

statiil  tliut 
"(•  likoly  to 
imrticiilarly 

not  ciiablu 
ice  the  cases 
)rk  ill  close, 
0  diet  is  iii- 
inoii  enough 
disease  and 
luensi's  have 
ulopiiieiit  ol" 
unstuiit  eoii- 
ds  are  iiiore 
iieiii  assoeia- 
i  ()rijj;iii  has 
he  view  that 
-a  coprcmia. 
i\v.     On  the 
PS,  who  liase 
a  shock  or  a 
factor  is  one 
e  entire  vas- 
N'irehow  has 
ative  organs. 
Di"  two  addi- 
yelluw-greeii 


few  months. 

stances  thei'e 

:  a  rclaji 

deferred   Im' 

ways  wi'll  '  ' 

so  in  men,  in 
patients  tivl 

l)Ut  there  is  a 
feature  is  its 

;tant  to  trcai- 


uorinal  nniii- 
^'theniia.     lu 


'I'll 

tmr 
Ida 

illir 


I 


HO' 

4 

'OS 

oos 

3,C 

.50fi 

«»;« 

2,0C 

SOji 

2(V;   1 

,fkM 

■-'( 

18 

ir. 

M 

1-'. 

10, 

X,< 

(i,( 

■1.0 

L'.W 

Pi(i.  ;!:!.-( 

'as 

•'•irpiisi^ii 

iKinnal  n 

pcriiicioiis 

mic  case 

fl 

|H  r  cent 

.  ( 

iiuuiIkt, 

av 

/>/v^...vAw  nr  rn,  n,on„  ,,-„  , 


/V/A/>rr/y.AXsw,7....V/.s'    ;„,., 


T'"''  ''■"'''•''  ''-■••''^-  wn.^.^.^l^.^^^^^^7^ 


'•'  '■•■IK.  ../■  t\\v 

i"T  .■••Ml.    ri,,-,^ 


>i:i"ii  \iiii:i; 


''''=HS^^^^^ 


'"•'•""•"•"■'^  ""<'->ia,  in  wl,i,.|,  tl„,  ,.i„, 


""<■  ''asc  f|„>  oli,r,„.vt) 


'lj|'l-'r  Villi.,.  i„  ]„.„m.rlo| 


"■'•  ;'""t.  oi- homoglobi,.     The,.,,! 


<;"".•!  was  pn.foiHul— 1  or)3 


,000  red 


minibi 


lorl. 


"''  "'"^^'"g  '"  ^h«  63  ca.es  studied  b^ 


-,.'-'<^,wu  red  corpus, 
■.«s  cells  w,.re  only  sliojitj 


i>iii  is  increased.     Ii 
>n"i«t'los,  wit],  ]7.,r] 


TJi 


y  increased  in 


fiyr  .S4G7  to  the  cnhi, 


niiJIi 


I 


910 


.l.V   AMKRIVAN   TEXT-BOOK    OF   Til  HliA  PFATICS. 


.11 


i| 


■\h. 


h    ' 


11 


„n-tcr— /.  r.  1  (•<)l(>rl»->s  to  408  ml  corpiL-c'lc.-.  One  nisc  with  over  Xo  per  ('I'lit. 
of  reil  globules  imcl  only  ;35  per  eeiil.  (jf  iiemoglohin  presented  the  clinical 
aspect  of  a  profound  anemia. 

The  treatment  of  chlorosis  is  simple,  and  in  the  large  majority  of  cases 
exceedin.dv  satisfactoiA.      In   protracted  and  >evere  cases,   particularly  when 


MAU 

II. 

ATI 

Ul,. 

__-„ 

M.W. 

— 

, 

zr 

io 

z 

s 

i" 

// 

/¥ 

/? 

20 

Z3 

lb 

29 

Z 

5 

8 

// 

/* 

'7 

IQ 

23 

=- 

. 

~~~" 

■"■ 

— 

— 



—^ 

1 

'    ' 

11(W 

.... 

lOCV't    5,000,000 

/i 

90r. 

/ 

— 

= 

— 

— 

«— 

1-^ 

*K    4,000,000 

/ 



/ 

IW, 

/ 

— r- 

/ 

eO'S    3,000,0(K1 

**" 

,-^ 

.•- 

p*'- 

50< 

— 

.^ 



f 

6,00<) 
4,000 

.:'. 

— 

— 

^ 

rrr 

^ 

-r. 

— 

... 

— 

... 

— 

.... 

— 

■-- 

— 

— 

.... 

,_. 

,/ 

2,0iKi 

~ 

1 

4-  - 

Fig  ■!!  -CiM.  ul-  .•l.l.n'uM.  «ith  nuirk.,1  „li-oohrnmoinia:  tlu-  rurvo  «  ro,,r.-s,-nts  the  m.mb..r  of  rort  .-r- 
punch's  ;  Mho  ,K.r,..nt«go  of  l.o.uoglobiu ;  o,  the  nun,!,.,-  of  .olorU.HS  corpuscles  ;  ,^  ,/,  the  mean  >,o,- 
mill  number  of  colorless  corpuscles. 

there  has  been  swelling  of  the  feet  and  much  breathlessncss,  it  is  best  to  con- 
fine the  patient  to  bed  lor  a  couple  of  weeks.  As  a  rule,  this  is  not  nece.s.sary  ; 
and  the  patient  should  bo  in  the  fresh  air  as  mudi  as  possible,  but  not  takmu 
much  exercise.  Among  the  poorer  classes,  however,  we  often  have  to  tivai 
ca,ses  in  faetorv-girls  who  are  unable  to  give  up  work,  but  even  in  these  the 
results  of  treatment  are  usually  quite  brilliant.  The  three  important  points  m 
the  treatment  are  correction  of  errors  in  diet  aixl  digestion,  regulation  of  tlir 
bowels,  and  tiie  administration  (jf  iron. 

The  <lirections  lor  the  hygienic  and  dietetic  treatment  are  those  ot    tlio 

lance  of  imr- 


sccoudary  anemias.     Great  str<'.<s  has  been  laid  upon 
gatives.  and  an  extreme  position  is  expressed  by  Sir 


the  imp 
\ndrcw  Clark,  who 


■ni'l 


that  if  he  had  to  treat  the  (li.-^ca.se  with  one  < 


drug  only,  lie  would  choo.se  a  purgi'. 

view  of  the  relations  of  coustipati'm 

I  fecal  to.xemia  to  tlie  disease.     Time  and  again  1  have  demo 


This,  however,  is  an  entirely  cxaggc 
and  supposes 


•ated 


'( 'S. 


wi^' 


Hii  per  (Tilt, 
the  clinical 

•ity  of  cases 
ilarlv   when 


20 

2i 

i 

.— < 

h 

!■ 

.... 

— 

./ 

iniliiT  of  rod  c»v- 
.  (I.  tlic  moan  uni- 


s  best  to  eoii- 
lot  necessary  ; 
lit  not  takinu 
have  to  tnai 
1  in  these  tlir 
:ant  points  in 
Illation  of  till' 


those  of  thr 
tance  of  pni- 
irk,  who  Mil' I 
loose  a  jiiii'l: '. 
f  constipali"!! 
have  (lemon- 


■■',  i 

1  ■ 

•111 

ill  :l 

!    ! 

? 

..k 


ll'o 


18 


At 

mil 


end 


«|i 


tlioy 
It  ve 
iiiid  t 
the  11 
opiiik 

who  I 
•'itiier 


<ii 


f'|>in|)(> 


idp; 


to  ll 


le 


^-IK'Cl 


-•t  f, 


orl 


I.  T, 

in  ell 


Jon 


"lMfi|lll.« 


It 


MOMS,  il 

t'(.([ 


ly-es 


.^ 


J>J-si:asi:s 


^'•'  yv/A-  nr^ 


•St  nil  (.(I  t 


OOD  Axn    nu-UCCTL 


ord 


"  '"y  -tialrnis  til 


ESS  (!L 


■  ■■    •'  ^  '••*liMi 


l-^7),s■    f»!i 


"miT  (SISOS. 


•'""'I'lt'C'  iniifilitv  of 


Ji 


onie  oases  ,milp| 


J>in'.iiiitivi'  1 


'''llC(llc>     I,,     f_. 


II IL- 


■salts  wiJI  ii.snall 


""•  is  ai 


III  ( 


Tl 


•*iilli(,'( 


■'^<rlleMt   I 


nxativi 


Tl 


"'  •■><seiitial  feat II 


'•-'  "nliiiarv 


"■<J"-     Almost 
t'f't's  and  ior  ^  j 


''<■  ill  (lie  tl 


l'iir^r;,tivc 


i!'  in  (iiv 


I    pCIK 


"I.  will  efl 


pJiatf, 


usua 


lly 


'"y  I'l'qwration  „C  ,i„.  ,| 

'•'"«•   I'llOllijI 

*"•  "i'  file  iiioivani, 
^''^•'■'1   ill   tlu.  t;,,.,, 
t'oiploy  ri.e  iuniinl 


'"'"lieu,   „rtll(Ml 


isca.sc  i«  t 


''",!;■,   a(liiiii)ist,.|.e,j 


!<■  adiiiiiii^ti' 


llinil  of 


c't  a 


I"   siitiicicnr 


l"'''pai'atioii; 


(•lire, 


i>iit  tliC   . 


<jiiaii- 


IlKl 


'    "'■  J>Jaiid's  ,,iIK,  J 


aiiioiii.'  tlifsc  / 


."•'■iicral  oj.iiii 


on 


^   h 


'  .U'lvcn  bv  X 


las 


"I' years  ;| 


OlTi 


Sll 


Pot; 


1 


At  first 


Ipl 
issii  i.arl 

Ti-afracaiitli., 
<J  make  iiineiv. 


U'liicvcr 


"•'*-'"  tlic  cliief  i: 


IV 


ivoritf. 


lalis 


I'lilv. 


ouo 


ually 


pill 


>oiiati,- 


>*'-\-  j)i 


a^i  .'is'i 


O'i.) 


lis. 


1-  s-  lit  It.  pil. 


iiiav  I 


luereascd  uuti 


>^'  given   three  t 


ondorso  the  foil 


J   tlii-eo  pill 


IIIH 


>*  a   dav 


are  tal 


pills  o.xcol  all  other  i 


""•"ig  .stateiiirnt  ,,,•  x^- 


en   t\ 


'"'d   then    the   d 


^^^iy  satisfic 
wjiial   j-esiilt 


<'''rii,<j:inoii,< 
^'  "lyself  that  eoll 


leiiieyer  :  "  J  ,|, 


"■ee  tunes  a  dn 


I 


P'eparatioi 


'  not  sill) 


ose  grad- 
■an   tiillv 


1-^  III  vi 


eairiies  wJi 


■'""':  indeed,  1  1 


Pl'"se  that  JJland', 


bel 


th 
It 


't-'vc  that  the  vi\ 


P'''»vided   only  that  tl 


"  ">'"le   n.e  of  oti 


lave  ]•( 


py  ran  he  ad 


minister 


"'"y  "'  lilaiidV  pill 


"y  gave  d 


KT  rei'i 


peat- 


oses  (,i 


I"'s  obtained 


^•fi'y  rarely  hapj,ens  tl 


"   111  verv  |j 


■aiiiiot   he 


'••I'""  size;  |„„    J  .^, 


irii'e  dose,. 


-'irpassed, 


so 


and  tlK"  reduced 


tl 


iron 


le  new  onrai 


'ill  any  oth,.,-  f 


^^■"hout  disti 


sinij)|y  he,.., 


Use 


sonietiine,' 


orin  of 


aoTee 


'Jpniion,  however,  of 


game  preparations  of 


iiearh-  so  efi 


men  who  1,;,^ 


wJio  have  I 


leaeioiis  as  tl 


iron 

e    llM'i 


•y'ter  with  del 
have  no  e.\ 


iron  is  needed.     Tl 


essin^r  the  patient. 


leate  st 


tl 


either  the  dia^r 


>eeii   uitihv  th 


le  iiioi-j 


aiiie  eon 


staiK 
^oi 


1  point. 


j:iio.si> 


or  tlie  treat 


previous  care  of 


leiii 
pound 


perien(.(..      '/" 
M.eiiis  to  he  ti^.^^   ,j 


le  earhoiiate 
oiiiaeh>,  l,„t  with 
'e  .ireiieral 
"■y  are  not 


"'eeiiio- 


!  OO    o 


npoiiiids  as  h,.,.f 


f'en    the  pj, 


'<>  t 


le  negleet  of  the  okh 


\viiie,  and  ir 


nieiit  of  old 
-i''i.'in   ha>  | 


praetitioiiers,  J 
<jro,,i-  i,;,,  ,.eaehed 


as   r  d, 


eaniiot 


]>atients 
-ay  that 


"11,  or  some  of  tl 


><'<'n   playii 


l<r 


with 


■'till 


I'lie  jiiod 


e  o 


i'  aet 


'•  >'"ip/er,  and  f 


'"   "nsettle<J  p,.ohl 


'•^■^netl  third  edition  of 


ion  oi   i|-,„ 


ir  iiioiv 


I   III  ehlorosis  has  I 


le  newei'  ,„.jr,, 
I'ofeni  nil,,.,/ 


^atisfhef,,,.^ 
siieh    faiieifid 


Ille   eol 


o/'oiiiid 


ii 


lein. 


5(111 


>et  fbrth 


hh  mlt^k 


ge  '    th 


"■en  niiieh  di.: 


'■"•y-   whieh.  I 


eiissi 


»0WI1    L,li,i,m-h^  he  J, 


■-'ee,  in   tl 


•I,  and  IS 


le  recently 


P 


1.  Tl 


revious  r)hservations   | 


'as  not  modified,  is  t| 


III.S 


le  inor<i;i 


nie  preparations  of 


ia\e    rendered   f]. 


ree 


'"  ^'niorotiesnhjeets;  '>.  Tl 


<'omains  onlv 


10  salts  of 


"'"n  promote  the  f 


eonelnsion.,   p,.,,!,.,!,!, 


"rinafion  of  I, 


orL'aiiie  f 


It 


ij>}>''ars  /( 


^i""s,  and  i.s  „o, 


foriii-^  of  j 
'  nie  that  the  ( 


r'ili 


"■<J"  :n'..  not  al.sorhed  at  all 


eiiioiilohin 


(), 


"ruaiiK 
''  '■  diiresi 


"PP"sed  to  aiiythin,-- tl 


"Ilowillij;'  hypotli 


"nipoiinds  of 
'v«'  eaiial   hv  the 


lat  we  h 


"••  .1  at 


e-l>  ! 
now 


eeoneih's  all  lhr 


w 


■ee  eoiielii- 


e   111 


{•reparations  of 


some  way  pro.oeted   f,,,,,,  ,] 


e  11111-1  as^iini..  that  th 


iron. 


ilphid  of 


eeonipositi,,||  i„ 


aniiuoniiiiu 


■Il 


li 


il 


!)12 


.I.V 


.l,l//;A-/r.|.V    TEXT-nOUK    OF    THERAPEUTICS. 


uraduallv  sonaralr>    tl.c    iron    tV.mi  tho   or^nmic    .■...npniUKl    of    iron.     Now, 

.lUalin,.". .biuations  nf  sulphur  a.r  also  found  in  ti.e  intestine,  ospmully  n, 

,li...s,iv..  .li>tnrl.an.v,  ul.icli  is  invarial.ly  on.  ..f  tho  >ymptoms  ot  ehloros.s. 
II  inoroani.  .-on.ponn.ls  of  iron  a.v  pn  ^  ..t,  they  will  at  ov..v  fix  thr  sulplu.r 
„f  thr  imsalinc  Milphids,  before  it  .'an  art  upou  the  organic  eonipomuls  „t  inai. 
The  laiter  are  ihus  preserved  from  decomposition,  and  are  absorbed. 

-  I,  appear,  that  in  chlorosis  the  amount  of  gastric  juice  secreted  is  msut- 
,i,u,H,  (.I'i.aps  bv  r..a.on  of  the  poorness  of  the  blood),  and  that,  in  c<^isc> 
,„,„,,,  ,l,,,n..niali've  organisms  are  introduced  into  the  intestine.  The  chief 
i'  „.,„,„.„  of  th,.  gastric  jui.v  probably  lies  in  the  antiseptic  action  ot  the 
free  hydrochloric  aci.l.  Should  the  amount  of  hydrochloric  acid  be  msut- 
,l,.i,,,t'lun..i  an.l  bacteria  get  into  the  intestine,  particularly  those  winch  pro- 
,,,„,,,  lii.ivric  f.T,n,.ntatiou.  In  butyric  fermentation,  however,  hydrogen  is  set 
,V,„,   :„„l'.  bv  ihe  reducing  action  of  the  nascent  hydr.-gen,  alkaline  sulphids 

arc  funned  iVum  ih .mpoiinds  of  sulphur  in  ilie  food.     These  decompose  the 

oi-rani. mpo.m.is  of  iron.     In  this  respect  a  recent  snggestK^i,  that  l.y-  ro- 

..hLrir  acid  is  a  re  effectual  remedy  fbr  chlorosis  than  iron,  sliould  be  taken 

in...  cui,si,lenvtion.     Again,  the  experience  of  physicians,  that  iron  is  only  o 
„.c.  in  cases  of  lv,>i..al  chlorosis,  an<l  lu.t  in  otlier  iorms  of  anemia,  agrees  well 
with  mv  hvpoth'c-i-.      in  all  tliose  forms  of  anemia  caused  by  disturbance  m 
bh-od-i-orii'iation  outside  the  intestinal  wall  the    preparations  of    iron   which 
cannut   be  absoriicd  are  naturally  useless.  _     _ 

>'  l.-inallv,  the  doctrine  .  .  .  that  iron  is  only  effectual  in  large  doses  is  in 
l.armonv  with  mv  hvpothe.is.  Considerable  (piantitics  of  iron  are  necessary 
to  nndrr  ihc  alkaline  sulphi.ls  formed  in  the  intestine  inert,  whereas  a  very 
small  amount    wonhl   suffice  for  the  formation  of  hemogh.bm."  ' 

On  the  other  hand,  there  is  some  experimental  evidence  to  show  that  iiior- 
tranic  iron  is  absorbe.l.  "  Knukel  fed  two  dogs  on  a  similar  diet,  but  to  one 
^ave  iron  in  a.ldition.  After  >ome  time  he  killed  them,  and  on  determining 
„,..  „.,„„„  „,•  i,„„  i„  the  various  organs  he  found  that  the  liver  and  ..ther 
oivaus  oi'  Ihe  .io.v  which  had  taken  iron  along  with  its  food  contained  coi.sider- 
aldv  lunre  than  those  of  the  other  dog.  Experiments  on  mice  gave  similar 
reM.li-.  lie  himself,  however,  points  out  ihat  this  experiment  i>  not  con- 
clusive, a,-  the  iron  administered  might  only  improve  digestion  and  allow  the 
i,.,n  of  til.,  (bod,  whi.'h  is  in  organic  combinaticm,  to  be  more  freely  absorbed. 

\nother   view,  the  so-called   stimulation-theory,  is  that  "  the  iron  ..i   the 
i;„„l    ,vhieh  <'.|uals  about  G  to  9  centigrams  .laily  in  an  ordinary  diet,  is  more 
than  M,tlici..nt  to  make  up  any  deliciency  of  iron  in  the  'olood,  and  that  nnuse. 
iron  i^  alwav.  b.^ing  excreted  f^'om  tne  bowel  even  in  cldoroMs.     1  he  intestinal 
.nncou.  m...nbrane,  however,  is  supposed  to  be  so  bhunlless  that  it  cannot  pmp- 


erlv 


iicrfoi'Mi  il-  absi 


>rpt!v< 


fiinetions,  hence  tlic  iron  o 


if  the  food  is  not  taki 


dvaiilage  (.f.     iJiit  when  inorganic  iron  is  g 


ivcn, I 


t  stimulates  and  tone; 


the  gasli'o-m 


)ei-iinal    inucoiH  mcmbraiK 


so   t 


hat  digestion  and  absorption  ol 


'  l'liii»iiih(iie(il 
'  Stockiiiiiii 


VhemiMr,!,  Weeiih'idfjes  triinsliUion,  j).  lOS. 


Brid 


,h  M.,l!nilJnuni(il,  l«'j;i,  1. 


ws. 

roil.  Now, 
L«pc't'ially  in 
of  chlorosi.-i. 
the  sulpliiir 
iiuls  of  iron. 
J. 

!to(l  i.--  in>iif- 
at,  in  c'(jnse- 
■?\w  (;liief 
lotion  of  the 
■id   be  insuf- 
V  which  pro- 
(Irojicn  is  set 
line  .-nlphids 
L'f'onipose  the 
,  tiiat  liydi'o- 
lulcl  lie  taken 
>n  is  only  of 
X,  agree.s  well 
listnrbanee  in 
"  iron   which 


ve  doses  is  in 
are  necessary 
hereas  a  very 

low  that  inor- 
iet,  bnt  to  one 
n  deterniiniug 
ver  and  other 
lined  eonsiiltjr- 
!  gave  similar 
it  i>  not  CI  111- 

aiul  allow  th( 
■Iv  absorbeil."' 
le  iron  of  tin 
v  diet,  is  more 
lid  that  nnns'-il 

The  intestinal 
it  cannot  prop- 
d  is  not  tak(  n 
;  and  tones  up 

absorption  of 


58 


ilwiiiioala-  will  ,,„,,  ,n      '■    '""»i"i.-  |.ivi«„.„i„„  "I'""",  as 

i.i|»iny,  and  on  (  „,  ,„i ,      ,  '   """   m.ii  siili, h  ,    „|„,   ,,,„    " 

"re  Jiist  a.,  ,,,,,„|,|,.  ,     .         ""«■'■  lani'l  llial   l,i,„„„,|,  ,„   ,        '"■""   "'=   "i-fs 

A-  n.  jra.„ii;,;;;  I,',"''"'"  "",'•'  ■■"  ■''i--">k      ' ■■  ■■'  »'■'"'« »» 

1"«  l«a  .Ionic      !'"" ""S"""  "«.-."al.       ,.         'T''?'""'  """■^  •■>'■= 

•■nt«,i„„l    „*;"'■"•":  """'"--■     In  „   I      ,r™         ".""  '"■  ""•  "".. , 

;™.«.-vi,m:;:  :;;;:--■■  '■« ".rrxr  *:,' /'■= 

''oucomitant  of  tl,oi,-  .,l  "-^'  •'^"""Jant  a.tion  flun-  .  'i"t'"'''al 

progressive  Pernicious  Anemia  n''    '"  '''""''-P'^'^'na."  ' 

;;;'7 ;*i.™t  a„,  „i,e„vo,;;;„  t  x;  ;:^^ '--  "f  g^neii  a'::t  I ;,:     ' 

'  "'*"'•  mn,n.utio,  slan.lnlar  ,er„„  !         '  "",''' '"'■""».  "»  l>'"l".i-a,  „„ 

:"  ■I--*.'™'.-!  .,•  .1,0  'o™;;  ;,*:;"': ''"  ^avo  ,hooi,a™„„,-„,„.,,  „ 

Ab.ract  fro,„  /..,,,  ,,.,,„,  .,^„,,,^^,^^  ^^^^"'^^'^^^  •^^,11  appropriate. 


\U 


it 


! 


914        .LV  AMERICAX   TEXT-BOOK   OF   THEItAPErTTCS. 

There  Ikis  of  late  heeii  ii  toiulcney  to  overlix.k  llii>  pniiit,  and  while  lh(Te  an? 
vai-ioiis  causes  that  inav  pruilii.e  aiien.ia  al  once  pro<iressive  and  i)ernicions, 
these  eases,  h.-wever  nuieh  they  may  sinmlate  it,  do  not  i.elon^r  to  the  type  de- 
s,TilK.d  l.v  Addison,  in  whieh  there  exist  none  of  "the  usnal  eanses  and  eon- 
ooniitai.ts"  of  the  ane.ni.'  slate."  Th<!  foUowin-  conditions  may  be  associated 
with  or  lead  up  to  profound  and  progressive  anemia,  which  may  he  conlound-nl 
with  the  true  i.liopathi.-  form  of  Addiso.i :  {a)  The  severe  p..st-partum  aiu^nua 
described  bv  (lianninir,  (iusscrow,  and  others;  {!>)  the  form  of  chrome  gastrUis 
associated  with  -reat  atrophv  of  the  mucous  membranes;  (c)  the  parasitic  ane- 
mias due  to  the  ankvlostoma  or  to  the  bothriocephalus ;  and  {,!)  lastly,  in  a  few 
rare  instances  of  carcinoma  the  anemia  is  i-arly  and  progressive,  and  the  patient 
mav  die  profoundlv  anemic  without  any  suspicion  that  a  neoplasm  is  pre>Hnt 

"Now,  apart  froiii  these  conditions,  whi<'h  are  more  or  less  readily  recognize<l, 
is  the  form  described  bv  A.ldison,  which  is  most  frequently  seen  in  males,  oc- 
curs in  the  middle  period  of  life,  and  in  which  the  causal  fa.'tors  remain  obscure. 
In  a  number  of  cases  oastro-intestinal  disorders  precede  the  atta.'k  ;  m  others 
mental  shock  or  great  worrv.  Of  late  the  thcry  has  been  advanced  that  the 
disease  has  its  origin  in  the  intestinal  tract,  and  is  due  to  the  absorption  of  poi- 
sons-ptomains  produced  bv  certain  micro-organisms.  These  are  supposed  to 
cause  rapid  blood-destruction,  particularly  in  the  portal  system.  This  is  fol- 
lowed by  the  deposition  of  increased  amounts  of  iron  in  the  liver,  and  accounts 
also  fbr  the  increase  in  the  iron  in  the  kidneys,  and  the  excess  of  pigments,  par- 
ticularlv  the  pathologic  urobilin,  in  the  urine.  This  view,  whieh  has  been  so 
stronglv  supported  by  Wm.  Hunter,  has  been  received  with  much  favor,  though 
oppos^it'ion  is  not  lacking,  as  in  the  recent  work  of  Hopkins.  _         ,     •    ,. 

The  clinical  features  of  idiopathic  anemia  are  very  characteristic.  An  indi- 
vidual who  perhaps  has  before  been  perfectly  healthy  begins  gradually  to  de- 
velop the  svniptoms  of  anemia.  Occasionally  the  onset  is  rapid,  but  as  a  ml.' 
it  is  so  insidious  that  the  patient  is  scarcely  able  to  give  the  exact  date  of  the 
beoinniiK^  of  his  illness.  He  becomes  paler,  and  notices  that  he  tires  easily, 
gets  out'of  breath,  and  has  palpitation  of  the  heart  on  the  least  exertion, 
Hea.lachc,  vertigo,  and  ringing  in  the  cars  are  not  uncommon  as  early  symp- 
toms. All  these  mav  be  gradually  aggravated,  and  later  on  the  pallor  mav 
b..  extreme,  the  skin  assuming  a  characteristic  lemon-yellow  tint.  The  diges- 
tive functions  become  <listurbed,  the  appetite  is  poor,  and  nausea  and  voniitin. 
are  frequent.  The  ankles  become  edematous,  ;uid  hemorrhages  may  take  phur 
into  the  nuicous  membranes.  The  end  is  grai-hi.'ally  .lescribed  by  Addisun : 
"  The  debilitv  becomes  extreme,  the  patient  can  no  longer  rise  from  bed,  thr 
mind  occasionallv  wanders;  he  falls  into  a  prostrate  and  half-torpid  state,  a„. 
at  Icucrth  expires;  nevertheless,  to  the  very  last,  and  after  a  si.'kness  of  several 
months'  duration,  the  bulkiness  of  the  general  frame  and  the  amount  of  ..Ik'siiv 
often  present  a  most  striking  contrast  to  the  failure  and  exhaustion  ohservaLle 

in  every  other  respect." 

The  prognosis  is  extremelv  grave.     The  disease  has  been  supposed  to  l)e 
invariably  fatal,  and  the  reported  cases  of  cure  have  been  regarded  as  example^ 


I'  tlicre  nro 
])t'i'iiici(«is, 
lie  typi!  lie- 
's anil  coii- 
e  associated 
t'ontouiKlod 
iiin  aiu'iiiia 
iiic  <!;astritis 
irasitin  aiio- 
ly,  ill  a  few 
tlie  patient 
is  pi'('>^!iit. 
recognized, 
a  males,  oc- 
aiii  obscure. 
: ;  ill  others 
ced  that  the 
)tion  of  poi- 
supposed  to 
This  is  fol- 
,11  d  accounts 
iTnients,  par- 
has  boon  so 
ivor,  though 


'.     An  indi- 

Inally  to  de- 

)iit  as  a  rule 

t  date  of  the 

tires  easily, 

ast  exertion. 

early  syni])- 

pallor  may 

The  dige^- 

nd  vomitiui: 

ly  take  phiri' 

by  Addison  : 

rora  bed,  tiic 

3id  state,  anl 

3SS  of  several 

int  of  oIm's'hv 


^l^  observa 


.pj)osed  to  1)^ 
1  as  examples 


hk  m 


( 

II 

/; 
II 
p< 

til 
p" 

ihi 

ill 

Ml 

cliii 


iio  i 

iisod 

Jiyr, 

treat 

speci 

less. 

An 

of  hrp; 

resciiil 

tlic  sul 

the  lip, 

not  Ion 

sub-ictc 

of  inorli 

elii'itwl 

i'l  ii  ma 

eould  n< 

wcro  oiil 

ahoiit  2(1 

nu'ilicine 

•1  'Ifiy,  f,) 

takin^^,  1) 

fontimio,] 

For  u\ 

colored  CO 

to  lo  dr„p 

the  drug  „ 

'0.8 1  aslig 

"Iv  (0.31)  J 

i'liprove  m< 

supervened 

(0.00065)  01 

%  June  13 

improved,  a 

s'-en  on  Sej 

lousiness,  an 


""'lit  witi 


'  ;"'"""'••  '"'^"s  i„,„ , 


""••"''i"  iiiiiv,,! 


'IcfiuM    |,\.   j{ 


V'"-' n,.i,„„,<„i  ,:;■"'■" ••"•^"'.-m.im., 


inuinvc 


•r 


' •''  r-  "'••'f    N,„,,|,„„     ;y, 


I"'i/iici(,| 


■"H'llllJI. 


M'h 


ipsc.s  ii/(,.,. 


•ii/ic 


^M'dllps  )j,(, 


:i|'|>aivirt  fijr« 


"•".u:r(w  „r  ,|n,  .,„, 


iirc  vci" 


'"'  frcaf. 
if'tioii  Jijis 


sc  ,. 


■'^l''^   into   ;i    / 


•'•'lllliluli. 


f'"'   ''<il<l  of  tijo  So 


l'!>|-ticill;iilv  (ll 


'<-'Oll(|;||-v  .\ 


ll'lllill 


in  fl 


''■""«  «li«'t,  \h\\ 


"•'  '"''"f  I'l  bod  MitI 


'H'lllll 


•';'"'■'•  ••'I'd  iVwU'tu- 


'"■'"  <•'■  n'l;i,,sin^r 


inc'i.' 


IM'Oi 


"'  'iitestiiios.    / 


K.'Vllllr   1),.,( 


I'll  till 


J>iitioiit  1 


"''■.^lill;il 


'  "'•''^N.uo.      ff,„„ 

"P<"i  tlii.s  tl 


"III    ill  I 


''"''"'   of  ,„„| 


'"f'^'I'lirs  l.nvo  I 


'K'l'i'  Jiro  /; 


<'!•  l'<'<'nni„i,.,„|. 


wcr 


lor 

•i^c,  iiioro 

■I"  exeJiisivciv 


"■''II  11.-0(1   (, 


Ji'ifn'/liofivo  o/i 
"ii'xit  tin 


iigos 


:5^rS=;5;£r~s 

«P-i/io,  and  ov   1    :r  "'"""-•     '"  .mai,   If    :'''-^"'"  -'—  in  the 

,  -^"-^-:'Zir;r"i  ^'"--'v:!:!:: """"-"'  -.--t  „o^.: 
;'-  Hps  a„„  ,o„„;;,:; : ;; : ;  --'"p^;i.  ^n.o„  fi...e ;  ^^'i ;;  '^  --'  *"  t.u.e  ..„::; 

^"'HoteroiVItintoftliei         T,, '"  '•""^^"t''"lark  clraiJl^'T''  ■'""■'--''•'' 
o  .  inocJorato  vol.uno.     \V   u  J      ••■">I'--ati.ro  ,vas  a  little  0";'?'''?'  •^■'"f-"-.vollo«., 

'""''I  not   1,0  ,„ado  at  tlio  ,i  ,      ,         '''"'"^''■^  "'' advanced  ■>!,  ^  "''""''  ■^'"'"•''•l 

"^•-'^  20.  „o  was  ,  ;  '  ::  '"^  •"  ^'"^  "•"-•  '-111^  ,  '  ,  J  ;•  '^^"/-■•■'^^  'aU'.-.  there 
""j-'i-nes  bismuth  ,md  s  H,  ;!;7"  «  '-"^-'-t,  ordo,  ;;',!;"'"'-'--" 'a.e  was 
»''".v,to  be  increased  ,„  '      " '"^'"""f''- «'itl.  I'Vnvler's  s  |,  ■-''  ""™ '-i ''«>%  an.l  as 

''^■'-^>  by  the  ad  i  T'  ,  "'7'  i':'>'>^>  «'aily  at  tl,  ^  "  ';'  "^^^  ''»''^'  >•  "-roe  tin.e: 
continued.  '"'^  '-''.-,0,,.,  a„  eli.vi,.  of  i      '     J  J'^^'  .  "^'  '"ad  been 

,F^"r  fwo  n,ontJ.s  there  w..  ,    .  ''^'"'"'  "■'"■^■''   "-^ 

"l^-  (0.31)  aeain  tlJ       ^"'•'■"^'''  'i"d  the  ars-nie  u-,    \         ,   ^-    **"  '•''adiinff  m  v,-;,- 

-p^m^ied,  .ith'S,r  ^;::t,?^"'  '^!r  ^-  wee.':;;:::,;::!!:^- ^-  -med  to 


fO.OOOfi.5) 


Fiv 


j;  or  ar,enous  acid  ordered     n.    t 


"e  13th  he 


riiiMvas  then  .stopjx.d  f 


gastric  irritation 


:ri!^':!'«r"'«^v;rs 


™-^;;^:;;";ri:r:--^^^ 


;'""">^^«l^t  the  patient 


"*'■  '"•'  'iays,  and  j.ills  of 


was  allowed  tr 


gr. 


incT 


:'•     '^'"^  ''lood-condition 


7  ''■''.'■''  "•''^'■ly  -»,ooo,ooo 


get  uj), 
rapidlv 


""^»-. ''-  «w:;;:;f'^  '™-»^'^  '■>»-.  i.rzr;:s  "■■■» 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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1   . 


moiogrdpmc 

Sciences 
Corporation 


33  WEST  MAIN  STREEf 

WEBSTER,  NY.  14580 

(716)  872-4503 


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916 


AN  AMERICA X   TEXTBOOK   OF   THERAPEUTICS. 


The  subsequent  history  of  this  ease  illustrates  an  only  too  common  feature  in  the 

disease.  ..,.,.  j    „<. 

The  man  remained  well  for  nearly  two  years,  was  very  active  in  his  business,  and  sat 
for  a  session  in  Congress.  Anemia  then  developed  again,  and  when  I  saw  lum  about 
four  months  after  its'onset  he  had  mucli  edema,  and  an  extreme  grade  ot  anemia,  from 
which  he  never  rallied. 

Fowler's  .solution  is  the  most  satisluctoiy  form  in  which  to  give  arsenic. 
Beginning  with  doses  of  from  3  to  5  minims  (0.18-0.31)  thrice  daily,  it  may  be 
gnrdualU^incrcased  until  the  patient  takes  15  or  20  minims  (1.-1.23)  at  a  dose. 
The  better  tlx'  patient  bi'ars  the  arsenic  the  greater  are  his  chances  of  recovery. 
The  drug  .'^honld  be  interrupted  only  when  toxic  manifestations  develop,  and 
then  aftcT  a  week  it  should  be  started  again  at  ihe  dose  the  patient  was 
takiuo-  when  the  toxic  symptoms  ai)peared.  Sometimes  a  patient  will  take 
ansenous  acid  more  readilv  than  Fowler's  solution,  or  it  may  be  necessary  to 
employ  the  drug  hvpodermicallv.  It  is  well  to  be  frank  with  tin;  patient,  and 
explain  the  liability  of  relapse,  and  to  urge  the  importance  of  very  careful 
attention  to  hygienic  and  <lietetic  rules,  and  on  tlie  slightest  indication  of 
oncomini!:  anemia  arsenic  should  again  be  used. 

In  a  few  instances  the  condition  has  been  relieved  by  iron  after  arsenic  has 
failed.     I  have  not  met  with  such  a  case. 

Of  other  remedies,  inhalation  of  oxygen  has  been  recommended,  and  there 
iiave  been  several  instances  in  which  ai)parcntly  this  has  been  beiusHcial.  Fraser 
Ins  recentlv  recommended  the  use  of  the  extract  of  bone-marrow,  but  in  the 
ca«c  which"  he  reports  arseni.'  was  given  conjointly.  The  patient  imjiroved, 
and  within  two  months  the  bhxKl-count  rose  from  1,000,000  per  c.mm.  to 
4,000,000.  Several  other  cases  have  been  reported;  one  by  Danforth,  in 
which'  also,  however,  arsenic  was  given  with  the  bou"-marrow.  Tlie  marrow 
is  very  readilv  prepared  in  the  form  of  a  glycerin-extract,  by  el  )pping  up 
sheei)'s  ribs  i'nto  small  fragments,  and  allowing  them  to  macerate  for  three  or 
four  days  in  glvcerin  ;  tlie  i)rodnct  is  then  strained  and  the  resulting  liquid 
administered  hi"  teaspoonfnl-doses  three  times  a  day.  I  have  recently  employed 
such  an  extract  in  two  cases ;  in  one  it  was  given  for  nineteen  days  without 
causing  any  improvement.  Fowler's  solution  was  then  ordered,  and  rapid 
increas^c  in"  the  corpuscles  took  place.  In  the  second  case  the  blood-count 
fell  during  the  use  of  the  bone-marrow.  Various  preparations  of  bone- 
marrow  are  now  on  the  market. 

Leukemia  and  Pseudo-lexjkemia. 

(a)  Leukemia.— This  disease  is  characterized  by  a  persistent  increase  in 
the  number  of  the  colorless  corpuscles  in  association  with  changes,  either 
singly  or  together,  in  the  spleen,  lymph-glands,  and  bone-marrow. 

Althou.di  we  sjieak  of  Ivmpliatic,  splenic,  and  myelogenous  Icukemias,  we 
rarely  see  a  pure  form  of  any  one  of  them.     The  splenic  fnrm  alone  is  mud. 
the  most  frwiuent.     Only  o,e  instance  of  pure  myologenous  leukemia  is 
record.     With  the  splenic  form  the  bone-changes  are  usually  well  mark 


nil 
C.I. 


Biiture  in  the 

iness,  and  sat 
i\v  him  iibout 
tuieuiiii,  from 

jive  arsenic. 

ly,  it  may  be 

13)  at  a  dose, 
of  recovery. 

develop,  and 
patient  was 

ut  will  take 
necessary  to 
patient,  and 
very  careful 

ndication   of 

,>r  arsenic  lias 

ed,  and  there 
Hcial.  Fraser 
V,  but  in  the 
ut  improved, 
per  e.mni.  to 
Danforth,  in 
The  marrow 
cl  opping  up 
;e  for  three  or 
Hiltiufj;  liquid 
itly  employed 
days  without 
(d,  and  rapid 
3  blood-count 
ous  of  boue- 


it  increase  ui 
[jani^es,  either 
•row. 

Icidiotiiias,  we 
nlonc  is  niu(  li 
eukemia  is  on 
well  niarkcil. 


1 

ii 


I 


J^ISEASJJS  OF  rrrr  nr^ 

'•'*/y     J//F   DLCTT  P^VV    r<r    .  ^ 

GiimVallv  and  ,nnt      •  "^'^^^^-^^  OLAyjJ.s.    mi 

J"  rare  instances  tlio    1 
the  bowel  <„•  i„  the'  ,,|,ar vn'r^''!  """  '""'-  '"'^"•'"'^'^•J  i"  the  Jvn„,|,  .1 

ano  some  of  the  fafil  ,..,  •  '•'"'^t.inia  and  the  info'tiun  , 

^^'•;^r  x\:;;'^'' '"-■"-:;»  t:;:\";; " ^.<; 

venienr-r.       \  ,  -THloinen    boi;,,',.    ti„>    .    .•  ■'•I'lenie  tunior 

«.^  w*^::  'X  T  '"■'  ■■ ' '■'  '"^  *'•  H:"t. ;-:" ""-'- 

and    I.n,       ,   •      .'        '^■''  "^'  "f'tie<N  tli'it  l,f,  I,      .  "''*t  lie  first  consut.s 

cs  ot  my  series  a  hov  niio  .i;,„i     ,.  ,  ^"'^  >ynij)toin.     f,,  o,„.  „<•  .1 

-ntiy  „„•,,.  „,,„,  „„,, ; , '       «,.,e,„«i»  ,„„,  ,^.,  ,„,„ ; ;  •    ; 

>•"'  m.  i,n,,i™i.  n,.  ,„„„;:  ,'',""■  ■>"M.i.-fi.Micios  „f  „,„ ,;,: ' 

-  «„  i„  „„  ,L.      ""  "■'""■ « "' -nu,„  a,„,  ,„:,;,::  •;,;'■;;;;;,; 

I  he  J:ver  beoonies  enlaro-od  .,t  ■ 

« a  pro,,,,,,™,  ,,,,,„  r  ■        ,       '      '"I'lY"  "'-  '■-■»■■     As<,V,  „    ' 


ti 


»-"-"a.«™«wm-^„:,r:Ltz' 


c 


!)18 


Ay  AMERICAN    TEXT-HOOK   OF    TJIERAPEVTICS. 


s 


^f  i! 


%\ 


'» 


iU 


ml(lisli-l)n)\vii  ill  cdlor,  or  in  cxtrciiic  cases  possilily  cliocolate-colurwl.  Very 
often  a  sinjile  glaiiee  tiirougli  the  niicroscopo  at  tlie  fresh  bh)0(l-sli(le  will  settle 
the  diagnosis. 

Lvnipliatie  leukemia  is  not  so  frequent.  The  cervical  glands  are  usually 
first  involved,  and  then  the  axillary  and  inguinal  groups,  and  suhsequeutly  the 
deep-seated  ghiiids  in  the  thorax  and  abdomen,  rsually  these  eases  run  an 
acute  counse.  and  may  terminate  within  three  months.  I  have  recently  had 
under  observation  a  case  that  has  persisted  for  eight  years. 

An  enormous  leukocytosis  might  be  mistaken  for  a  leukemic  condition,  but 
may  be  easily  excluded  by  the  .study  of  stained  speeimons ;  in  all  ordinary 
leukoeytoscs  the  increase  affects  solely  the  polynuclear  ueutrojihiles.  The 
enlargement  of  the  spleen  in  chronic  malarial  cachexia  or  malignant  disease 
mav  also  be  differentiated  from  leukemia  by  the  blood-examination.  It  cer- 
tainly is  ni)t  justifiable  to  make  (as  has  been  done  in  at  least  one  ca.se  of  leu- 
kemia) an  exploratory  abdominal  incision  to  examine  the  spleen  before  the 
blood  has  been  carefully  studied. 

The  pure  lymphatic  form  of  leukemia  has  to  bo  distinguished  from  gen- 
eral lymiihadenonia,  or  Hodgkin's  disease ;  in  the  latter,  however,  the  glands 
are  found  in  much  larger  bunches;  and,  besides,  the  blood-condition  is  in 
lymphatic  leukemia  quite  characteristic. 

(/;)  Pseudo-leukemia,  or  Hodgkin's  disease,  is  characterized  by  progres- 
sive hyperplasia  of  the  1  •mph-glands  with  anemia,  and  sometimes  with  the 
development  of  secondary  lyiiii)liatic  growths  in  various  organs. 

Etiologii. — At  jireseut  we  must  allow  the  term  p.seudo-leukemia  to  cover 
certain  groups  of  pathologic  conditions  that  before  long  will  be  recognizeil 
as  definite  and  distinct  diseases.  One  has  only  to  attempt  to  accpiaint  himself 
with  the  literature  of  Hodgkin's  disease  to  appreciate  the  hopelessly  confused 
condition  in  which  the  matter  at  present  stands.  There  is  a  growing  convic- 
tion, especially  among  the  (Jerman  clinicians,  that  in  at  least  one  class  of  cases, 
if  the  patients  live  long  enough,  there  develops  a  true  leukt'inia;  and  certainly 
there  are  several  instances  recorded  in  which  under  direct  observation  sucli 
a  change  has  taken  place. 

Hodgkin's  di-sease  is  more  common  in  the  young,  over  GO  per  cent,  of  the 
cases  occurring  in  persons  under  forty  years  of  age.  That  it  is  an  intectiou- 
process  there  would  now  seem  little  reason  to  doubt.  What  the  infectious  agent 
is  we  do  not  know.  Those  cases  in  which  pyogenic  cocci  have  been  found  niv 
to  be  looked  upon  as  pseudo-leukemias  with  a  complicating  septic  infection. 

Sif)iipfomatohgi/. — As  we  are  at  present  forced  to  include  under  the  name 
of  pseudo-leukemia  conditions  varying  so  widely  in  a  jiathologic  sense,  it  will 
of  course  be  impossible  to  lay  down  a  ty  ':'•'.  and  definite  series  of  .symptoms 
applicable  to  all  cases. 

The  variation  in  the  rate  of  growth  and  in  the  size  of  the  glands  at  dliln- 
ent  times  is  astonishing.  When  they  have  been  large  they  may  dimiiii>li  in 
volume  or  even  entirely  disiippear ;  a  rapid  diminution  in  the  size  of  tlie 
glands  shortly  before  death  has  been  frequently  observed. 


orod.  Very 
lie  will  settle 

s  arc  nsually 
iwiuoiitly  the 
•ases  niii  an 
recently  had 

ondition,  but 
all  ordinary 
|)hilf'8.  The 
niaiit  disease 
ion.  It  ccr- 
!  ease  of  leu- 
n  hofore  the 

(1  from  gcn- 
I",  the  frlaiids 
ndition  is  in 

I  by  progres- 
iies  with  the 


uia  to  cover 
le  recognized 
aint  himscll" 
ssly  confused 
wing  couvic- 
■lass  of  oases, 
uid  certainly 
rvation  such 

'  cent.  ()<"  till' 
an  infection- 
ectious  agent 
!en  found  an 
infection. 
iei-  the  name 
sense,  it  will 
of  symptom-^ 

uds  at  dillir- 
•  dimini.-h  in 
;  size  of  the 


J>  IS  BASICS 


'>!'  Till:  /if. 


T\ 


^>f>n  Axn  rin: 


"•  •'^!>l''«'n  is  „rt, 


f>rrTLKSS  (ij^A 


xns. 


'yp'H'lioii.lniMi..     Til,,  ti 


"  ■-"ni<'k'nth-  ,.„|„. ,1 


Siiy 


.sfaii 


<f's   lll(>  t|,v, 


Tl 


Mll> 


i.vn.iil  y|j,,„| 


tl 


pJidVrit  iii.iv 


;is  u,. 


IK'CJISK 


'"■  •'•■'^"y  l'.''l|'.'.l.l.'  in  tl,,  left 


'"'••'•'    iltiiiMf 


M"  nil  i;,,. .,  I, 


'liitllll 


"'  *'""'""■"  :"i(l   t|,„  ,,„,j 


'■mil  ill 


'■|"''^t'll if  (lie  t 


•■;;"Hi.iai,iiM^onittio,.is„ti„„t) 


"  ■^'"  j;ni(|ii;ill 


Mlllois. 


IC  111- 


y  .ipjKar.     Flo  I 


')"f  S(ri|<i,|^r|v    I 


""1,  and  <|\ 


';"';  ^^''"'f'"''-  "'-ntal  ,„■  nl 


Pliysicjil;    ,,1, 


"'^'■"^   X'  /■"••■I   lan.M-ui.i 


sink   I 


""■;  111  onlv 


'".""  ^"'■""<"I.     Til,.  |,lo,„| 


ma  ,)/•  ,|„.  I 


(■ir.s. 


in   tl 


owiT  tlian  L>,()(ifi( 


100 


"""■  MiMaiic,.  I 


ia\-,' 


IS    in. 


Il'l-C 


"'"I"  niniil),.|-.     'I'j 
""■^i«l<Talil,..      ,„  „,,.   ,, 


l«'i'  f.iiii.i. 
11(1  cxtr. 


I 


''"lint 


■wii  tl 


as 


ni(. 


'••■lativoly  incivas,.,!.     )V| 


III 


111,1   iilh'n   tl 
jioikil 


'«■  ivd  |,|,„„|. 


'f'ff  IS  no  ,1 


II  rule, 
''orpiisfles 


•''■•■iitial  ,.,)nn(   t| 


»|'vt,isi.- 


•''■i'<';isc  at  al 


ic 


■■'■"'  Hi,.   I,.„|<,„.vt 


osi... 


'.^"'I'liocytos    a,,,,,.;,,.   ,o    I, 


^^  '''iikcniia. 


•should  ascertain  uli,.t],,.,.  ,.,.  .    T        ,  "'  ''""■'  ""''   i''  it   lie  ..  „• 

^•■om  tube,-eulo..s  a         ;;    "' ^ ''''^ ''-' '--ama^,..     T  ^  i  iT       '•'    •"" 

'l-tinetion  a,,  as  ftX  '    T  f      ,"""  ""'•'^  '"ffi""^-     Tk     •     '  "'"' 

;;^-.  the  antei-io..  an.I    :;!!; H^i-irLl^^r^''^^-.-  ^^-"  '''-    ■-■''i;^ 
latter  are  nu.rc  fre,,nentlv  tl.,.  ,1...^  a      .|  e    ;     IV  r;"""""^'"''''  -'-'--  tlieso 

A  Jong-standin.r  afKrti.in  „f  '  '^"•'^^'^'"'■'  'lisease 

^'-  P-ess  to  otliL  l"Z    Z7Tf''''  "'^'"'"^  -"-tendon  of 

_^-<"""'»'  Of  Leuk^ia  i:;':;'! ':.:"■;■'""■>■  -'" i>  ■■»«. 


>f 

je 

■so 


',    "'  .mivery  lias  nn,l„„|,t,dlv  ,k.,.i,i.,.„  I        7       '  """'''■'■  l'"''"<l-     Np,.n 
-ko^-tos  disappeared,  but  tli.  1   ,"'',*"•  7' /"''•' ^'='^  ^''"  '-- 
•'■•"^'"ibored,  l.„uever,  that  in   l,„  ''""■•uslH.d  in  volnnu..      f,  ;,  ,„    ' 

'^  -treinel,  variahle.     tL  '  a        ..:;::'  ""''  '--'•"-l-l<^.na  ^^ 2^^ 
--i.t.on  may  pe,.i.t  indeed  to.,  .i^^,,  ''""  "  r"'^' ^'— -,  aiul  th 

"measure  of  health.     M.ieh  .lepen  if  .^   ,     '  '"'"'  r^'  ^'^  ''^'tention  of  a  f a  r 
~a,  and  if  the  red  I.l.i..,lJ.:  td^''!^,  "'"";   ^''^   '"—  <"•  al>senee  of 

--.on,  the  patients  may  feel  v  ,",;"!;  ["'^^'^  '^^  ^  "<^  1-  cent.,  as  i^ 
Arsenif  !«  tlw>      i  .  •   '^oiniortabje. 


^Iionld  be  given  syste 


rem,.dy  that 


anemia.     I  Jiav 
oi'  this  di 


systemutieally  and 
■('  several  very  interes 


«'oni.s  (o  hav(.  a 


"1  niereasitijr  d 


"y  positive  influence,  and 


•»i?  in  leukemia.     The  el 


ting  charts  si 


't^  "o,ses,jnst  as  i 


It 


n  l)erniei,mg 


'""•ing  the  benefieial  effects 


Tr.Uook  of  Medicine,  of  a  Z   k"  .    """r"'  '"  '">•  -'^-le  in  the  A 


»ie)-icnn 


"■^^ -  "'-™«on  ,™r8;;::,z' 


i'i 


! 


t  i 


920        ^i.V  AMKIUCAN   TEXT-liOOK   OF    THKnArKmcS. 

1890,  to  XovciuImt,  1H!»2,  is  imrticiilarly  iiitoivsfiiij^.  Tlic  It'iikcmia  was  of 
hii'li  irnulc.     On  admission  there  were  500,000  U'likocvtcs  and  2,000,000  red 

*  1  •  1 

corpuscle's  per  c.nini.  From  Jaiuiary  2!>  to  Ftl)rnary  21  tin-  patient  took 
arsenie  in  increasinjz;  dos((s,  and  the  eolorh'ss  hloud-cor|»nseK's  iell  IVoni  71  1,000 
to  7500  per  c.inni.,  and  tlie  red  i)Iood-c<)rpnseles  increased  to  ;},500,000  per 
e.nini.  Tlirougii  the  months  of  March  and  April  tiie  leukemia  entirely  dis- 
appeared, and  the  colorless  hlood-corpuscles  were  ollen  helow  4000  per  e.mm. 
The  lar<^er  the  doses  the  patient  can  take,  the  more  heneficial  the  drun;  would 
appear  to  he.  It  is  best  given  in  the  form  of  Fowler's  solution.  I  have  used 
it  hypodermically,  ami  in  several  cases  have  followed  Mosler's  j)lan  of  direct 
injections  into  the  spleen,  which  has  not,  however,  any  special  advantat-es. 

In  Ilodidxin's  disease  arsenic  also  is  the  most  trust  wort  hv  tlrutr,  iuid  under 
its  use  the  glandular  enlargements  may  diminish  remarkably.  Caution  has  to 
be  exercised  in  these  cases,  as  arsenical  neuritis  may  occur.  I  have  reported 
an  instance  of  Ilodgkin's  disease  in  which  severe  peripheral  neuritis  tleveloped 
after  the  nse  of  f.^iv  ."j  V\\\\\}  (125.)  of  Fowler's  s()luti.)n. 

Of  other  drugs,  iron  is  sometimes  us(,'ful  when  there  is  pronounced  anemia. 
Phosphorus  in  doses  of  gr.  ^^  (0.0022)  three  times  a  day  has  sometimes  seemed 
beneticiid.  Inhalations  of  oxygen  may  also  be  tried.  The  residts  are,  how- 
ever, very  variable,  and  as  in  most  of  the  cases  arsenic  has  been  used  at  the 
same  time,  it  is  ditlicult  tu  say  how  much  of  the  beuelit  was  due  to  the  oxygen 
alone. 

Cold  douches  in  the  region  of  the  si)leen  may  be  tried ;  and  electricity  i)er- 
haps  may  give  the  ])atieiit  a  feeling  of  comfort  and  satisfaction  that  something 
is  being  done  for  him.  Notwithstanding  tl.e  fact  that  the  disease  is  almost 
invariably  progressive,  the  practitioner  can  do  much  to  relieve  distressing 
symptoms.  Care  should  be  exercised  in  the  use  of  purgatives,  as  an  acute 
colitis  is  a  not  infreipient  and  sometimes  fatal  complication.  Hemorrhages, 
which  are  always  dangerous,  are  to  be  treated  according  to  the  usual  methods. 
Very  litth;  can  be  done  to  relieve  the  dragging  sensations  in  the  side,  but  warm 
applications  often  give  relief. 

The  surgical  treatment  of  leukemia  and  of  pseudo-leid<emia  is  not  very 
satisfactory.  Of  twenty-four  cases  in  which  the  spleen  has  been  removed, 
only  one  recovered.  In  cases  of  Hodgkin's  disease,  when  seen  early  and  only 
a  few  glands  are  enlarged,  if  there  be  no  ctichexia,  removal  may  be  considered. 

A  few  cases  have  been  treated  recently  with  bone-marrow,  and  in  one 
instance  rejwrted  by  Lawrie'  the  results  were  very  striking. 

Addison's  Disease. 
This  remarkable  affection,  a  sort  of  cachexia  characterized  by  asthenia,  irri- 
tability of  the  stomach,  and  increjused  pigmentation  ()f  the  skin,  is  associated 
in  a  large  proportion  of  the  cases  with  disease  of  the  suprarenal  capsules. 

The  pathology  of  the  disease  is  still  olxscure.  On  the  one  hand  it  has  been 
urged  that  the  symptons  are  not  due  to  disease  of  the  adrenals,  but  to  involve- 

•  British  Medical  Journal,  Dec.  1,  1894. 


r/rs. 

icmin  was  dl' 
>.()()(),()00  ir»l 
patient  toiik 
IVom  71  J, 000 
5,r)()0,(KM»  per 
,  entirely  dis- 
i)0  pel'  ('.mill. 
1'  (iriiu  woiilil 
I  have  us('<l 
plan  of  direct 
^■anta;i'es. 
ijjj,  and  under 
'antion  lias  to 
liav(>  reported 
itis  developed 

uice<l  anemia, 
otinios  seemed 
ilts  are,  how- 
1  used  at  tiie 
to  the  oxygen 


ilectricity  ])er- 
liat  sometliinii; 
•aso  is  almost 
ve  distressini; 
s,  as  an  acute 
Ileiuorrliaircs, 
isual  methods, 
ide,  but  warm 


a  is  not  v(»rv 
leen  removed, 
nirly  and  only 
be  considered. 
',  and  in  one 


asthenia,  irri- 
I,  is  associated 
al  capsules, 
nd  it  has  been 
mt  to  involve- 


V. 


[til 

. 

i  f 
I'M 

L 

k 

1 

h. 

k 


!. 


I 


f 
ti 

ai 

!»• 
ca 

in 

till 


]•( 


1 


■e| 


(loi 
at  it 
Mil 
iroii 

SI1J)J 

1 
this 
<liot 
to  a 
acid, 
•liarri 
coiisti 
tlo.s(>.s 
back  i 
accord 
Th 
called 
Addist 
firoven 
In  a  c£ 
lias  los] 

Villains 


DISEASES  OF  rnn   nr 

'"•^"f  "f  the  ,ra„.||,  .,„  ,  ^^^^  f'f^A.YDs,    921 

^•-<'  the  syn^pto,!;;:,.     t  "m    "^ '"  '^'''^^^^^^^  --ton,      ()„  .         , 
a<lrciial,s       A,',-  •'^'"*'*''' ■'"  <>'H' to  ,list,n-l,..n,.     V    .  ^^"  ^lie  other 

"i»<I"|iiaov_t|,,,  "  ,i,  ""■''"'  "■'"■k  fatli.T  f,v,„     ,  "  ''''■■'""'- 

A  ,„aj„,.ilv  „|- ,1,,,  '  ("""M"!.).  -'I"'".',!.- <M|Uos„™ 

to  ii  stnollv  ,1,111;    II        ,,      ,,' "'""'l«"™t»  ,,„■„„  !,..„     .         •     ""        i 

«-"i".K  .o  G„i„,,i„,i.,,,.  |„  „„;  '^     - !-»"  .Hod  ,„  „  „,, .,,  ;  J 


'St  tJie  oxtronie  upaU 


remains  in  good  ,;oncl 


^;j«t''y  nn<l  cl,.|,i|i,v  fron.  „l,i;.| 


;"'^'''  ."■■"^'toen  ponncLs,  and 


'tion  afW  oigl.t  nmnths''V,vr.'  "^  '"'f  ^"  '"'^'-''•«'-     "« 


\h 


I'i 


i>22        AN  AMERICAN   TEXT-BOOK   OE    THERAPEUTICS. 

no  change  in  tin;  pigmentation.  The  ghmd  is  given  in  the  ibnn  of  a  glycerin- 
extract,  and  tiie  patient  may  receive  at  first  the  amount  ecjuivalent  to  one,  ami 
subsequently  to  two  or  three,  suprarenal  bodies. 

ExoPTHALMic  Goiter  (Graves-  Disease  ;  Basedow's  Disease  ). 

Although  this  disease  has  a  very  complex  syniptoiuatology,  in  its  fully 
developed  forms  it  is  readily  recogni/cd  by  the  triple  features  t)f  eidargement 
of  the  thyroid,  exophthalmos,  and  rapid  heart-action.  Ft  occurs  much  more 
frequently  in  women  than  in  men,  in  the  proportion  of  al)out  12  to  1.  It  is 
sometimes  seen  in  several  members  of  a  fiimily.  There  is  a  remarkable  in- 
stance on  record  of  an  hysterical  woman  who  had  ten  children,  eight  of  whom 
had  ext)phtlialmic  goiter,  and  one  of  these  children  had  four  daughters  with 
the  disease.  It  is  not  very  uncommon  to  see  two  members  of  a  family  afTected. 
\Vorry,  fright,  and  depressing  emotions  precede  the  development  of  the  disease 
in  many  cases.     In  a  large  number  diarrhea  has  preceded  the  onset. 

The  symptoms  come  on  gradually,  although  there  is  an  acute  form,  with 
vomiting,  diarrhea,  and  even  maniacal  outbreaks.  To  the  well-recognized 
triple  combination  of  exophthalmos,  goiter,  and  tachycardia  there  has  been 
added  a  fourth  cardinal  symptom,  namely,  tremor,  which  is  present  in  a  very 
large  proportion  of  cases,  and  which  is  of  value  in  the  diagnosis  of  the  early 
and  masked  cases.  For  the  more  special  features  and  symptomatology  of  the 
disease  the  reader  must  be  referred  to  the  manuals  of  Practice. 

Three  principal  views  have  been  advanced  to  account  for  the  pathology 
of  the  disease :  first,  that  it  is  a  neurosis ;  second,  that  it  is  an  afPcctiou  of  the 
medulla  oblongiita  ;  and  third,  that  it  is  really  a  disease  of  the  thyroid,  and 
that  the  symptoms  are  ilue  to  perversion  of  the  functions  of  this  gland.  Tiiis 
latter  view  has  been  particularly  advocated  by  ^r()bius,  Greenfield,  Joff'roy, 
and  others.  The  following  are  the  arguments  in  its  favor,  which  I  take  from 
a  recent  paper  by  one  of  my  assistants,  Dr.  Oppenheimer : 

(1)  ralholofjic  aiudomi/.  All  autopsies  Jiave  disclosed  some  changes  in  the 
thyroid  gland,  and  frequently  these  have  been  in  th(,'  direction  of  functional 
hyi)erplasia.     In  some  cases,  however,  the  gland  wiis  almost  completely  fibrous. 

(2)  The  adion  of  flii/roid  extract.  Soon  after  the  discovery  of  thyroid 
therapy  fi)r  myxedema,  Murray,  and  later  others,  warned  against  the  effects 
of  overdosage.  These  were  notably  tachycardia,  tremor,  headache,  sweating, 
prostration  and  anorexia,  diarrhea  and  jjolyuria.  At  a  meeting  of  the  Societe 
des  Hopitaux  held  Octoljer  12,  1894,  Bederc  ri'ported  a  case  in  which  exoph- 
thalmos developed  after  an  overdose  of  thyroid,  and  at  a  later  meeting  of  the 
same  body,  J?allet  and  Enriguez  reported  some  experiments  on  a  dog  in  which 
they  injected  thyroid  extract.  The  dog  had  two  courses,  and  in  each  developed 
goiter,  which  diminished  and  disa])peared  when  the  injections  were;  omitted. 

(2)  The  usual  effect  of  thyroid  administration  in  exophthalmic  goiter  is  to 
increase  the  symptoms.     There  are  exceptions  to  this. 

(4)  The  most  .successful  line  of  treatment,  so  far,  is  that  tending  to  diminish 
the  bulk  of  the  goiter.     Out  of  sixty-eight  operations  on  record,  completr 


TICS. 

oC  ii  ^lyceri li- 
nt to  one,  and 


Disease). 

y,  in  its  f'nlly 
A'  cnlargeniont 
rs  much  more 
12  to  1.  It  is 
•emarkal>le  in- 
?i<rht  of  whom 
huighters  with 
I'amily  afFoetod. 
t  of  the  disease 
iset. 

'ute  form,  with 
veil-recognized 
here  has  been 
eseut  in  a  very 
is  of  the  early 
lutology  of  the 

the  pathology 
ifFcction  of  the 
e  tiiyroid,  and 
s  gland.  This 
ntield,  JoflfVoy, 
•h  J  take  from 

changes  in  the 
I  of  functional 
pletely  (ihrous. 
:ry  of  thyroid 
nst  the  effects 
iche,  sweating, 
of  the  Socicte 
which  exoph- 
meeting  of  the 
I  dog  in  which 
„'aoh  developed 
jre  omitted, 
iiic  goiter  is  to 

ng  to  diminish 
[jord,  completr 


J^fSKASES  OP  rni'   ,,, 

'•wovLTv  K.II„n-o.l  ,.i.r|,t,,,„   ,„  ,.  ,  ^'^ 

('^)T],e  ..trikinj,  ,,,ntr,st  ..<•        '"""•''''>"*  -I'H'.i.    1;J  p,,-  cent 

"...^«io„..  T,,.i  .,:,■':;„:;:,,:■  '7;::;v:'"- -;i""! ■•.•  :'«.•..,.  „„„ 

""■'■■'  '■'-"■iilly  m,,|,r  „„■<,,„■ 

K\iii.i,ii,..i....- 


'■•'"''''"'"'Ii"i''i.'<.itur,.\lrs    V 
Pulse  ,,„  "K^''l  <MM.n,.t.,„. 

Kves  ''"■^' sound  Joutl. 

Thyroid'    '.■;■■■      i'''""''"'-^""""v.(;raof.'.ssien) 
Tremor     .  '    '    '      ■^/"""^'"•'^■"Hy  enlarged.  ^ 


M.vxt'ilcnia  (M,-s^  li,  ami 

tliirly.Ki.vuui. 
•58-70. 
^'egative. 


Skin 

Face 

IVnijifranient  .    . 
'Wfiglit 

Thyroid  treatment  . 


Moi.st;  .sweiits. 

Flushed;  red  pntehes  on  cheeks 

;';»'ot,o„ai  and  neurotic. 

'"•'"'  "'  ''^'  ""'i'ti'<l   because  of 
""•■•casein  symptoms.) 


^'I't  pn.Miiiieiif. 

Not  1(1  |)e  mad,,  out. 

Ahsent. 

J'ry  ii'id  liarsh. 

"-"vy  and  full;  uniform  color. 

Apathetic  and  heavy. 

I'^^i'  lioiiiids. 

^ ''^'''''''>'  '"'Provement  and  ,,,„,. 

(«)  Finally,  the  course  of  tin'   V        '  ■  ''''^'—m-. 

probable  that  the  ehlef  hnu.t  of  tiT     '  '•   ?,?  '"^''  '"'  '"t'>^--atio„.     It  is 
ton,  a„.l  this  ..o„l,l  ,ivo  rise       ,      ,  ir"""  '''^  ""  ^''^  •-^'•^l  nen-ouss- 

Treat.,.,^Tl.  disease  ,';'•'  ^^''"l*^"'-  -^'-"t  .narked  lesiti 

;'f  treat,..e„t.    Change.  <.fd,.ntt,     p„,    "  ,       /"    /'"      ,"'  ""^  ^'""'"'  «-•-« 
'-y-'  '"  -'K>  eases  In-  ,„,,,,„,    ,  "'*'    f  "-^'-■ato  elevation,  has  been  fol- 

-t'7  -^'  the  heart,  ttn.l  perhaps  hv^  j-o,!"  "'ri"     ''''"'  ""'^''  ^•^"^-  '-I'i'l 

"'-.pprchension  exists  as  to  the  etfe  'I^!^       '^  T  '™'"*"'^''  ^"^''^  ^''^'^  "■»■-'' 
'•"•■O  ""  the  cire,  latorv  or,an   .  •  ?     'T'^'''«^^ ^I-^vations  as  this(;i2oO 

-■vous  states  whieh  st.h  rC^  ^1  r'  ''='"^  '''  -'^•^■-  '■"'■•■t  d.  the 
'■"•""'^>t"'T  organs,  an.l  the  pun.v"  !  '  'l'^^''-^^'^^^^^  '"ost  tavon.blv  o„  the 
strengthening  „.d  .vstonttiveXt:''       ""  ^'"''^^  "'  '^'^  ^''-  '"'-  ^' ^-entl 

Systematic  hvdroihefiov  „;fi 
TI.0  »ot  pack  caVofnllv  .piilk       nrtr;;,"'","'*™  '"  *"""'  "'■'■  '■""<««"■ 
'"««"■.  ,„  allay  ,l,„  ,;,,.    i,v  „,,;         ™"  '';'  ','""■'-  "'""  -'y  "-!.«:  sin.'k 

'-".V  case*  ™„„ivo.     ,i„  ,,;     L^,    ,    "  '"        ■    ;"■•'■'"  ■■"'"«■■■'"■'  "'  '-  '" 


i\ 


m   ' 


:1<\I 


924 


AN   A.^fERJCAN  TEXT-BOOK   OF    THERAPEUTICS. 


TIio  dnig-treatinont  of  tlio  disease  is  most  iinsatisfiujtorv.  Helladoiina  is 
perliiips  the  most  trustwoi'thy  inodicanient,  and  should  be  given  until  it  pro- 
duces ])liysiologic  etteets.  I  have  never  seen  any  good  results  from  the  use  of 
ergot.  The  vaseular  depressants,  such  as  aconite  and  veratrum  viride,  are 
rarely  indicated.  Digitalis  will  sometimes  do  good,  particularly  in  the  anemic 
cases,  when  combined  with  iron.  In  the  advanced  stages  of  the  disease,  when 
the  heart  begins  to  fail  and  edema  appears,  T  have  seen  it  prove  very  beneficial. 
Stropiuuithus  has  also  been  employed.  The  combination  of  potassium  bromid 
with  valerian  is  often  usefid  in  allaying  the  excitable  condition  so  pronounced 
in  many  cases.  In  the  paroxysms  of  urgent  dyspnea,  with  ])alpitation  of  the 
heart,  liy])o(lermie  injections  of  morphin  may  bo  tried ;  Trousseau  recommends 
copious  venesection.  In  some  cases  in  which  these  paroxysms  are  most  pro- 
nounced, a  whole  scries  of  remedies  may  be  tried  without  avail.  The  diarrhea 
is  sometimes  obstinate  and  difficult  to  treat.  Thyroid  extract  has  been  used  of 
late  in  many  cases,  nearly  always  with  injurious  results,  aggravating  th(>  jialpita- 
tion  and  increasing  the  nervous  condition  ;  although  in  some  cases  great  benefit 
has  iieen  reported. 

In  a  few  instances  attended  with  hypertrophy  of  the  mucous  membrane  of 
the  nose,  or  ])olypi,  treatment  of  the  local  conditions  has  been  followed  by  etn-e. 

The  surgical  ti'catment  of  cxo[,iithaliiiic  goiter  has  of  late  proved  luore 
hopeful.  Excision  of  ])ortions  of  the  gland  has  been  practised,  and  in  a  few 
cases  ligation  of  the  arteries  passing  to  the  thyroid  has  been  bencficial. 

Myxedema. 

A  disorder  that  follows  loss  of  function  of  the  thyroid  gland,  characterized 
clinically  by  an  infiltration  of  the  subcutaneous  tissues,  in  children  by  an  arrest 
of  develo})ment,  and  in  adults  by  the  gradual  production  of  a  cachexia  in  some 
respects  reseiubling  cretinism.     There  are  three  groups  of  ca.ses  : 

1.  Cretinism,  Sporadic  and  Endemic. — When  there  is  congenital  absence 
or  atrophy  of  the  thyroid  gland,  tht;  infant  is  born  a  cretin  and  does  not,  as  a 
rule,  survivi!  birth  very  long.  The  body  is  stunted  and  broad,  and  the  subcuta- 
neous tissues  over-developed.  Sometiiues  the  child  shows  only  slight  traces 
of  the  disease  at  birth,  but  as  development  proceeds  the  condition  becomes  very 
manifest.  There  is  a  subcutaneous  myxedematous  swelling;  the  head  is  large; 
the  neck  short  and  thick  ;  the  li])s  full ;  and  the  tongue  large  and  oflen  pro- 
truding. Mental  development  is  extremely  slow.  In  some  cases  the  thyroid 
gland  cannot  be  felt ;  in  others  there  is  slight  enlargement ;  sometimes  there  is 
a  definite  goiter.  In  other  cases,  the  condition  does  not  develoj)  until  between 
the  third  and  fifth  years.  Cirowth  is  retarded ;  the  head  becomes  dispro])or- 
tionately  large  and  broad,  the  nose  retrousxe,  the  lips  thick  ;  the  limbs  are  short, 
the  subcutaneous  tissues  infiltrated  ;  the  sk'in  has  a  .glossy  a|)])earanc(!,  and  there 
is  a  thick,  solid  edema  above  the  clavicles.  The  voice  has  either  a  rough  or  a 
stridulous  character,  and  the  hair  often  i)econies  thin  and  scanty.  These  changes 
are  usually  progressive,  and  reach  their  maximum  between  the  twelfth  and 
fifteenth  years.     The  child  never  properly  matures,  and,  the  condition  remain- 


KUTICS. 

.  Rclladonna  is 
iven  until  it  pro- 
<  from  tlic  uso  of" 
itriiin  viridc,  aro 
rly  in  the  anoinic! 
the  disease,  wiien 
ve  very  IxMieficial. 
[)ota,ssiiini  hroniid 
jn  so  pronouneed 
|>a]pitation  of  the 
<seaii  recoinniends 
ms  are  most  pro- 
il.  Tiie  diarrhea 
,  has  been  used  of 
atinsi;  the  palpita- 
?ases  great  benefit 

Dus  niend)rane  of 
followed  by  euro, 
ate  pi'oved  more 
ised,  and  in  a  flnv 
3n  beneficial. 


I>IS1;asi"s  ( »r  'I'll  I-  . 


'■'''■:^^^«;i.AXi.s.  |.,,,.,,v) 


md,  characterized 
dren  by  an  arrest 
cachexia  in  some 
es : 

'ongenital  absence 
md  does  not,  as  a 
,  and  the  subeuta- 
)idy  slight  traces 
ion  becomes  very 
the  head  is  large  ; 
e  and  often  ])ro- 
cases  the  thyroid 
ometimes  there  is 
loj>  until  between 
conies  dispropor- 
e  limbs  are  short, 
\'irance,  and  there 
ther  a  rough  or  a 
f.  These  changes 
the  twelfth  and 
condition  remain- 


i 


111- 


li:        111 


i>r<Tij:ss  arAAns.   do;, 


If/SEASKS  or  Tin-  III,.,  , 
'"W  Mationary,  at   tl...  (w,.,,,:,.,!,   ,  „ 

'"7--  -itl.  .1...  fn,.,,i.,.  .,•,,,'„       ""•  ''-I"!........  of  H  Koit..,.  H,at 

(V,...M.s,„   imvaiN  ..xt..„Mv..|v  ■ 
"'r  '-"^  "'•  '•"■'^.•Mi.al   an.l  ,,,iv     .JZ!' '!"  '"  "'''"''  ^""'■'-  '^  '••"'-"-.  and 


-^""•'■'-      -^'"-Kl.  I  was  al.l..  ,..,;" 


"'  all  <'iiinitri(.s.     Tl,,,..  .„.,.  ,...."    •' 
I  ■      I  IK  V  .lit'  rare  m 


'!"-'> -"I  i,  i.  ,,..,.  i,.,,.,,„„   „.„  r^"""''7-,-.  ^  <l.i.-l<.  nn,   i,.,W.- 

2.   Myxedema  Pi-oper.-TI...    ii  """•^  r''^'"'''  ^^^  '•"•"^^"i..d  .arlv. 

-M   u.  ,1..  ,,„,„„„•„,  ,,,  ,.  ,^^  •'-  's  n.o,v  (n.,,,u.Mt  in  .onH...  tl,a„  in 

;;;>■;  -.i...  -,...., o^.m. ,;„, J t;"':^;'-  "-  ^.,.,.0,.. .,os,...i.....i 

..  oIow„,g  n.ay  I,.  ,.„„..u.,.a,..,l  :  Tin  .."l.  ,'"'"' "'^'  '"''"'  "'"  0-|..-i....s 
"  /'-  'xxly  :  .In.  linn  swdli...  of  Hi.?'  '":''"""'  '"  "'<'  ^<'"-"l  "'"He 
"""T"  "  "'"'  '"''^^  '-"-'tl.,;,.|  ;;  '  7  '"^^'"-  ""  •"•'-">v,  inelastic, 
'•"•'^'"'-  ••'•  'iH.  skin,  ,..n.||  .   ,        i     '  ^:'  ^'^-  ^'-"'"-"  ;  tl...  .Iryn..ss  anj 


Ijy  fVionds  and  ob.sorvors  "  ^  ""  '"^"-'"pts  at  inteiTuption 

''"•■f-"  on.  n>n<lit;;„   i.I.,w;!!r!;:!.  "■  """;"'"'  -'■'"^'l«l-tl.o.,-adual 
th 

and 


■'-••f'>it..avo,,n.nan..;l:      ,:    ^^^^^^^  ^'^  ^^'^l'^'^'  ^-"i-^  Uo 

"•'1  others  have  sl.oun  that  if  .,  sm,.,II  '  ;  .  ^^'^^ '-'■^■P"•"»ent.sof•Hol•sk.v 
<•-  ao  not  oceui-,  and  in  H,',:::':  ::;Z;;^^ '-  -'-'"  ':e  1^'ft  these  syn.,; 
ccos,sory  j^lands  have  been  nn.. n.       ','      1"'."""  '"  """"'''^  tl'at  H.rvivc 


<i-(>ni  tlie  l)a.se  of  the  t( 


'en  present.     The...-,.  | 


tlie  hvoid  1 


>"giio  to  th,.  aorta  ;  thvroid  t 


liave  been  fonnd  in  all 


situation)- 


in  the  Clinical  Society 


;o"e  and  in  the  trachea.     Of  4(),s\.onm| 


«  i-oport,  my.xedcma  developed  in'tjli 


1  tissue  has  even  been  found  in 
picte  thyroidectomies  analyzed 


iiii 


926        AS   AMKllICAM   'ft:XT-nnnu(   of    TIli:iiM>rj'TTf'S 

'I'licM'  three  (Additions,  (||rn — cietinism,  tiiyx<'<ltMim  |)ro|K'i',  aixl  optrativc 
iiivxedema — not  u\x\\  *tMi>A  in  el<c*«'  relation  to  eari,   other,  hut  are  in  reality 
identical  atli'ctioiis,  in(U»,t«<<^f^•  the  hw.^  of  the   fimetion  of  the  'liyroiil  jrlaml, 
whieh  wonlil  appear  to  supply  ."   u.    nmterial  iiooeswiry  to  the  tairttiitenancp  of 
the  normal  nietaholisin,  more  partieui.jrly  of  the  eonneetive  tisHiies  of  the  body. 
The  dia.uniosis  of  the  varions  forms  of  myxedema  rarely  presents  anv  ilif- 
ficnilty,  hilt  ill  lioth  ehildren  and  adults  theeondition   is  likely  to  he  mistaken 
for  nephritis,  particularly   if,  as  is  sometimes  the  ease,  the  urine  is  slijrhtly 
alhnmiiions.     The  solid  eliaraeter  of  the  ech'tna,  however,  the  state  of  the  thyroid 
gland,  the  presence  of  siihcntaneons  swellings  aliove  the  clavicle,  are  points  that 
should  lead  to  a  diagnosis.     The  color  in  myAcdema  is  iisnally  more  yellow; 
that  in  chronic  nephritis  a  waxy  white.    The  pntliiiess  and  swelling  in  niyxedoma 
are  more  ditruse  and   firmer,  and  pit  hut  slightly.     The  swelling  of  chronic 
nephritis  is  most  marked  in  the  legs,  and  one  rarely  sees  that  general  siihcntan- 
eons inliltration  present  in  myxedema,  in  which  disease,  also,  the  rough,  harsh 
.skin  and  the  distiirhance  of  the  nutrition  of  the  jiair  are  often  present.     Then, 
mental  nnd  ccrchral  features  are  more  coninioii  in  myxedema,  particularly  the 
Jitnuhieh     ft'eliiii,     of  fatigue,  and  incapa<'ity  for  mental  eil"ort. 

^'ertuin  sym])ionis  occur  at  the  time  of  the  menopaiiso  in  women  that  iiiav 
cause  difficulty  m  diagnosis.  There  may  he  slight  swelling  of  the  face,  ofteii 
with  a  little  dryness  of  the  skin  and  pallor  not  unlike  those  of  myxedema,  and 
occasional  swelling  of  the  feet. 

Treatment.— As  the  patients  suffer  a  great  deal  from  cold,  they  should 
be  kept  warm,  and  when  possible  should  live  in  a  mild,  e(iuable  climate. 
IMcCall  Anderson  has  advocated  the  treatment  by  warm  baths,  shampooing, 
and  Turkish  baths,  combined  with  the  use  of  arsenic,  strychnin,  and  i)ilocarpin. 
The  use  of  the  thyroid  gland  in  the  treatment  of  myxedema  by  Dr.  G.  K. 
Murray  was  a  brilliant  deduction  from  the  physiologic  experiments  of  Jlorslcy 
and  others.  The  literature  <,,^  the  subject  has  grown  enormously,  and  several 
exhaustive  summaries  have  been  made.'  It  is  quite  settled  that  the  administra- 
tion of  the  thyroid  gland  of  animals  will,  within  a  variable  space  of  time, 
remove  the  symptoms  of  the  disease,  whether  the  case  is  one  *■■(  sporadic 
cretinism,  or  of  myxedema  proper,  or  of  the  cachexia  strumipriva. 

Mode  of  Adiiiinisfrafion. — The  gland  may  be  given  raw  or  cooked,  or  in 
the  form  of  a  dry  powdered  extract.  It'  given  cooked  it  shoiJd  onlv  be  par- 
boiled. Dried  extracts  and  tabl  .i^'*  are  now  to  be  had,  and,  as  anile,  an; 
(piite  trustworthy.  It  makes  in  r  '■>•••  no  (h'fference  in  what  way  the  gland 
is  achninistered,  so  long  as  proper  car      ^    i.  !n  to  -?lect  healthy  glands. 

The  glycerin-extract  can  readily  K-  ^,a,h  hy  any  practitioner.  Several 
dozens  of  thyroids  of  young  slieej)  ,-.•  a;.'!.':  ire  carefiiW  .-iparated  from  the 
connective  tissue,  cut  into  small  piccei-t  aboi;'  the  size  of  a  bean,  and  then  put 
in  a  jar  and  covered  with  glycerin  of  the  best  quality,  allowing  2  c.cm.  of 
glycerin  for  each  lobe  of  the  thvroid  used.     The  mixture 


pen 


I  stand 


Tlie  fullest  is  liy  Iloiiisheiiiier  :   Knlwickrliiiifj  und  jdziger  Stand  der  Schilddrusenbehandluny. 


Miinchcn,  189.J 


'I',  uiid  oiwrativp 
il  arc  ill  iciiliiv 
('  fliyrniil  jj;laiiil, 
tailTflteiiaiicc  of 
(IK'S  of  the  body, 
ii'osciits  liny  diC- 
tn  he  inistaki.'ii 
iriiic  is  sli;;litly 
to  of  till'  thyroid 
',  \\\\\  points  tliat 
\\  niori'  yellow  ; 
iijr  ill  niyxt'dciiia 
lliii}^  of  du'oiiic 
incnd  siiiiciitaii- 
Ih'  rough,  liarsh 
l)r('S('iit.  Tiieii, 
particularly  the 

k'omoii  that  may 
■  the  face,  often 
myxedema,  and 

1(1,  they  should 
Mjual)le  cliiiiatc. 
bs,  shampooing, 

and  pilocar))iu. 
a  by  I  )r.  G.  R. 
cuts  of  J  lorslcy 
sly,  and  several 
the  administra- 

spaco  of  time, 

lie   >A    sporadic 

ipriva. 

!•  cooked,  or  in 

Id  only  be  par- 

,  as  a  rule,  are 

way  the  gland 

glands. 

ioiicr.  Several 
rated  from  the 
I,  and  then  put 
iiig  2  c.cm.  of 
mitted  to  stand 

il<lrusenbehandlun(j. 


iJ 


i 


jyi^EASJ^S  or  THE  BLOOD    i  ^v;    rjn, 

^iA/>    'm:  DUCTLESS  GLANDS.    9»7 

'"'•  <\vonty-four  or  tl.irty-.ix   I 

about  liali' a  .r|.,„,l    „       ,    "\''MH'>Mblo.     Of  f),,-,   ..  •"'  'Hi,  .so 

;'-^-  r'^-ti-  of  ..a,.boii.  .^i^    n :  7';  '^  ''^'^'«'  J-if a  .1,.;.!  (,, .., ,  ^  ; 

/>o,s.«^,,_()ft,,^^    J  •  t'",..  or  four  tnn.s  a  week-. 

Jt  ...  Mell  to  hogin  with  7n,i  or  mii  ,  )  Xi.'""     .„       ''■'''  "'  '■"''"'"''"  ■'•vxo.lc.na 
"---0  until   nix  or  mLiJ  Srt  ;       t''"^'"'--'"'''^'-'-'^'^ 

Murray  d.vulos  the  troatu.em  o?     '  .— ^"^  ^'"'^'^^  ^''""^^  «  dav. 
"^  t he     ,„,,„„^  ,,.  ^,^^  ;t  o,  ,  ^^.^^  .tagos-tirst,  the"  removal 

^"'f'^'--  ^''ti..firststa«.Vi  .rr^-^''''"''''"^-'--'-'''^ 

and  gradually  inerease  then^     The    vLto     ""1  ''"'"'''''^y  ^^•'*''  -"='"  <i'-'^ 
r-'cdyare  flushing  of  the  tnjt^"^^''"^:':^  ^-"-'M-l  i"tro,lnctio„  of  the 
'^o,  fainting,  and  in  son.  oa"'  ^ZP       '''  ""'  '"  ='  ^''^  '-tanees  v  ^ 
i-art-aetion,  with  profile  p.rs,lS^t    \  "r"'^'"'"     ^^"I''<>  -^'1  ^-0 
ever,  not  to  suggest  to  the  panln    t     '.  "^     T  '^r  '"^^^''-     ^^  ''^  "•^■",  Ih.w- 
"";^ward  syn,pton.s  are  in    .a  i  ^       e"  T^       '^^^  "'"  ^'"  ••^•-^'^■'  '-  'hi 
r'\^"  t^^-  or  three  weeks,  an.n"     s;,,,/^"'  ^"'"^'^'^-^----'-allv  notiej 
''as  been  remarkable.     TIk.;  eff  e     •  ""'  T'"''"  "  '""'"''  "-  ^'''an^! 

f^volhng  and  the  loss  in  wei.h,      1"  "rT  I!'  *^^  ^'^"'"'^l  ''-l.-tion  of  tte 

sl-gbtly,  reaching  normal,  and  the   C-^  .C!^'  ^'^  ^-"I-'^'t.-   i.Leases 

In  «tsesof  infantile  -nyxodema-eon.^  h  ,r       •''  ^''*^'"^'  "'"''^  ^'^^'ve. 
^•en.arkable,  and  son,,,    .f  the  ill„    i  r  '''"'■''"-^'^^'^'''anu^'sarensnajlv 

In  a  .use  under  n.y  ...re  there  oeenrre  ,,'""''  T"  ''"^^  «'^tonishing.        ' 

entu-e  loss  of  the  ere.inoid  aspeet  •  the      I      ,    "  '""^^  f  ^^•"'•^-"  '""nths  .u.        i 
■'"proved,  and  the  flesh  l,eea Lo  f  r„    „  T7  ^""'''  *''''  """'■"■""  ^-^atly        ^ 

and  tnc.eased  fbur  inehes  in  he  !  ;":;;'' Z''^' ''''^'r'^  <'--l.>pod  n,.idly 
;-  and  M-alked  about  evervwl,;:  1^:1""^  '•''';  '"  -"^.  ^Le  now 
-^•■aordman-.      At   the  Ix^inning,  ,ho  .  , !  ''^■,  T'"^"'   ^'--lop.nent  vas 

^'.0^  ke<I  clearly  and  said  ahnost  eZhir'     ''''"      ^'"  ^^"^^-"  '-ntl.; 

^'•«';"'ont  is  interrupted  the  svn.p,:,,,    '  r  T\         ^^■""■■"^''<^'l.   but   if  the 

"ot  been  long  enough  in  use  to   ,1  ! ";     ;:;':'  ^"  T"';     ^bo  treatn.ent  has 
-t..ct  .n,  ultin,ately  l„.  abando.L  !  V'l  T  ""!''"'  ^'"  "^  ^^'  ^»'« 

tH.nnn.i,.      T..  .  ^".      "  •iH  Dmbabdity  it  has  to  be  usi  ' 


(be  same  beneficial  results  1 


■lave  resulted  from 
ave  followed  the 


surgical  exti 


con- 


J'pation  of  the  gland 


administration  of  thyroid  extr 


■act. 


■'   i 


11 


DISEASES  OF  THE  KIDNEYS. 


J*.v  .JAMKS  TYSON. 


While  alterations  in  the  d.omic  and  niorph„]o^.ic  composition  of  the  urine 
are  the  consequences  of  other  than  renal  a.i.l  vesical  atfecti„„s,  the  dia<nK,sis 
of  such  affections,  with  the  notable  exception  of  .liabetes,  depends  for  the^niost 
part  on  other  symptoms  than  chanj,^es  in  the  urine,  while  the  indications  for 
treatment  are  as  seldom  based  on  such  changes.  In  the  case  of  the  diseases 
whose  treatment  is  to  be  considered  iu  this  article,  a  thorough  study  of  the 
nrine  .s  an  indispensable  condition,  as  on  it  largely  depends  the  accuracy  of 
diagnosis  on  which  a  rational  treatment  must  be  based. 

Prophylaxis. 
The   prophylaxis   of   inflammatory    conditions    of  the    kidnev  may,  in  a 
word,  1)0  said   to  be  the  avoidance  of   their  various  causes.     So  far'a's   the 
infections  diseases  that  are  the  most  common  cause  of  acute  nephritis  are  con- 
cerned there  is  little  to  be  sai.l,  as  accidental  circumstances  beyond  our  con- 
trol are  generally  responsible  for  their  visitations.     Canimt,  however,  some- 
thing be  .lone  to  diminish   the   chances   for  tli<'  operation   of  such   causes^ 
I  ndoubledly.  in  certain   instances.     Particularly  is  this  true  of  scarlet  fever. 
I  am  confident  that  nephritis  is  a  much  uiore  infre(|ueut  sequel  of  scarlet  fbyer 
to-day  than  it  was  twenty-fi\-e  years  ago,  because  of  the  greater  care  now 
taken  during  convalescence  from  this  disease.     Formcrlv,  when  children  were 
allowed  to  be  up  and  go  al)out  the  house  and  even  out-of-doors  when  dcs.piama- 
ti.JU  was  barely  complete,  nephritis  and  other  seciueke  were  much  more  common. 
It  IS  a  matter  of  extreme  importance,  therefore,  that  children  with  scarlet  fever 
should  be  carefully  guarded  during  convalescence.     Desquamation  should  be 
thoroughly  complete  before  they  are  allowc-d  to  leave  the  sick-room,  while  the 
tivoi.lance  of  currents  of  air  is  of  extreme  importance.     Seldom  are  less  than 
six  weeks  sufficient  for  this  purpose,  and  this  period  should  be  insisted  upon 
even  in  mild  cases.     This  becomes  the  more  reasonable  when  it  is  remembered 
that  mild  cases  are  really  mor(>  likely  to  be  followed  by  nephritis  than  severe 
ones.      Why  it  is  that  the  ne])hritis  after  scarlet  fever  is  excited  bv  exposure 
during   convalescence  rather   than  at  the  time  the;  j)oison  is  most  active  is 
not  clear,  but  the  fact  remains.     It  laav  bu  that  the  chilling  of  the  skin  thus 

already  overwroutrht  in 


induced  throws  enough   more  work  on  the  kidneys, 
their  efforts  to  eliminate  the  jioisrm,  to  produce 
not,  however,  limited  in  its  occu 


928 


an  inflammation.     Nephritis  is 
rrence  to  this  stage  of  the  disease,  as  it  not 


rs. 


•x'xn 


isition  of  the  urine 
ions,  the  diagnosis 
r)ends  for  the  most 
the  indioatioiiH  for 
ase  of  the  diseases 
ough  study  of  the 
Is  the  accuracy  of 


The  Cerei^ai  CoMplications  of  Raynaud'. 

Disease. 


cidney  may,  in  a 
1.     So  far  as   the 
lephritis  are  con- 
beyond  our  con- 
,  however,  some- 
of  such  causes? 
of  scarlet  fever. 
;1  of  scarlet  fever 
greater  care  no\v 
len  children  were 
when  des(jnama- 
'h  more  common, 
vitli  scarlet  fever 
latiou  should  he 
-room,  while  the 
ini  are  less  than 
he  insisted  upon 
it  is  remembei-ed 
ritis  than  severe 
itcd  hy  exposure 
;  most  active  is 
of  the  skin  thus 
overwrought  in 
n.     Nephritis  is 
lisease,  as  it  not 


BY 


WILLIAM  OSLER,  M  D 


rxuM 


THE  AMERICAN  JOUKNAI.  OR  THE  MEDICAL  SOENCES 
November,  1896.  ' 


*l 


■ 

t 

i 

1 

I 

■j 

1 

Kxtracte.l  fnini  The  A,,,,.,.;  i 


I'l!liri>S(i|;   (,],    , 


"'•'  iiAVXAi-rrs   nrsKAsK. 


»AV\.VII)\    ,1 


norvolis   systt 


lsc;|v|.    , 


"iiy  cniniilicat 


tl 


"'  '"<'>t  iviiiarkiilil 


"'•     I'lTliajis  il 
'VstcTia.    ('as,.  \- 1 1 1. 


(•  niaiiv  aiTccti 


II'  iiKist  f'r( 


'Oils    of    tllr    riMit 


III  liavnai 


'I'"'"'   'lfs.,.7i,.r  with  whi,.) 


1(1  s  orii^iiia!  t 


piiriixvsiiis  iif  |,j, 


"  <'\-aiiiiil(.  "u   iv,.„r,I.      \Vi,|,  ■;", 


ifsis  IS 


ral 
1  it  is 


iH'i'lia)! 


•'oiitractiii 


■('■■',  and  ai 


'"  ■■""'  ''"'-il  a>|'liv.xia,  si 


ial-cs|;,.      'I' 


It:  liiid    livst(.ri,.;i| 


l"">t     !l-:,J.;,Vi.(,M! 


a^vatod  ,.xa.npl,.s.     I,,,.,,/, 


K'  lilcratii 


re  ('(intaii 


'•"iiviii>i(iii- 


wlio  rccontlv 


t( 


L.ai    f 


dix'usscd   tl 


''"'"'■   Xi'uriili 


1^  a   iiiiMiiirr  ,,f  |,.,<^ 


"rill,  iiiiliiicd   I 


COIl.|.i,.t,.ly  hv  Iiy|,l,„si 

'layiiaiid's  d 


"'  '|ii''>ri(ai,  Ii„|ds  i|,,,t  tj 
'1  cati.scvs,  and  \v| 


r/'''/'"'.  •lamiarv  ;!()    \ 


N'.»; 


'J, 


'y  ciiKitioii, 


it'i'c   i>  a  piiivly  11 
lii'ii   may  ii,.  n'licvVd 


Hcasc  is  not 


In-  S)iul,ey.^     Tin.   dis 


(W 


ILMl 


■'wortli/ 


i-^(>asc 
"111  in  aciii 


at  all  1,1 
lias   I),,,., 


K'oiniiioii    in   asvli 


'iii-i'ascs,  as  iKitrd 


'    ""'f   ^^'tl'  ill  .■i.il..|iti,.  d 


twoiity-throc  years,  | 
at'iito  mania  111.  stood  on  | 


lad  hai 


;■  'iiania.       |!laiid 
'i'^  fVoni  his  tliiri,. (.11(1 


'■nii'iiiia 


111  tiio  feet,  an,i  at  tl 


11-'  fi't't  forciM-ht 


patient,  a  iiial 
1  -.car.     r 


e   a; 


Kitti^  1 


HI: 


I't'ported  t 


"'  -^aiii,.  time  |)ar,.xvsniai  I 


'ii.^-lits.     Thed 


II  an  attack  of 


isi.as(.  d 


level, II 


peri,)d  ,.f  ,U.,,|.(„, 


^^■"  <'ases  ill  w!ii,.|,  |,„.al  as 


la'inatiii 


la  oeeurreil. 


Tl 


le  disease  has  | 


ere  are  i 


«ii«'   spinal   eor,|.      '1 

with   liydro,.e,,halns,  tuo  o7tl 

T.  K.  :\r 


'•'(•II  noted  ill  manv  el 


i-lpliyxia  devehipe,!  in  tl 


./'" 


ii'onie  affections  of  the  1 
'1  ■•('<'  instances  at  I,.ast  of  tl 


le 


irain 


'«  <'as,.s   in   adult. 


a-'  asso,.iat 


1011 


':":'"'"  "  ••''"''  -'f  nineteen  nioiul 


and   on,.,  i 


pateho8  of  |„eal  asol 


•  levoloped  syniiiietri,.ul 


phyxia  in  ,liff,.,-oi,t 


'nxl  Iia.l  from  hirti 


I'cjiioiis,  and  at  tl 


•''porteil   by 

lll0ttl(.(l 


111  t'oiiiieetioii  wit 


faii,<,nvn,.  of  the  toes.     Tl 


H'  aj,re  men t ion, .d 


Visceral 
i^iniilar  to  tli 
are  exeeedint;! 


1  syrinjroinyelia  and  with  I 


lore  are  instance: 


iianifestatioiis,  t 


"•■^e  "111,. I,  |,r,,dii,.,,  th 


H'  ex-pressi,)!,  ,)f  vasciil; 


oconiotor  ataxii 


also 


\'  I 


attacks  of  eol 


ai-c.     In  a  few  inst 


f  jH'ripheral  pi 


'I'  I'lianjres  of  a  kind 


fK'iioinena  ,)f  the  dis 


•edema  ;  lint  I  |, 


''  "•■•■'"•  not  unlike  those  which  ,1 


mces  ,«astro-iiit(.stinaI 


case, 
ci'ises  and 


know  of  no  jiost- 


iiorteni  rep,)rt  of 


eveloj)  ill 


an<,nonenrotic 


Keari  bt'liirt.  tlie 


■lease  ill  wlii(.|i  ,.| 


la  n  lie: 


'■  Oiiotofi  in  Hii 


Ampriaun  Ncnrolosicnl 


-"ins.  I'ati 


Aiiimlcs  Mi.(iieii-P 


lloWsAppoudix,  Sy.leilli 

xxxviii.  1SS7.( 


igicnl  Society,  iSflfi. 


!l.  ■'^1)0.  I,oii(I. 


mm  Society  Seluetetl  M, 


«  (ilui 


'Kou-  Moiliciil  J 


louriml,  WM, 


iio^niphs,  ISSM,  p.  iiiij, 
'  Liuict'l,  issii 


;i 


■!  1 


2       (»SI,KI{:     (^OM  IT.IC ATFON'S    OF    RAYXAUD's    DISEASK. 

ill  tlio  organs  have  beon  foiiiid  at  all  suggestive  of  prolonged  local  dis- 
tiii'haiH'c  of  tlie  circiilatioii. 

Occasionally  there  are  symptoms  })ointing  to  serious  disturhnnces  in 
the  functions  of  the  liraiii.  A  numherof  the  ])atients  have  been  epilep- 
tic ;  but  with  the  exception  of  the  first  case,  to  which  I  shall  refer,  I 
know  of  no  instance  in  which  the  attacks  a])peared  to  be  directly  asso- 
ciated with  the  development  of  Raynaud's  disease.  In  Case  XIX.  of 
Raynaud's  original  thesis,  usually  (pioted  as  an  illustration,  the  woman 
had  e|)ilcptiform  attacks  which  preceded  and  were  jiot  sp(>cially  related 
to  the  gangrene  of  the  feet  of  which  she  died. 

(^ur  attention  was  directed  to  cerebral  symptoms  in  the  disease  by  a 
patient  at  tlu'  Johns  Hopkins  Hospital,  whose  case  is  reported  in  full 
by  Dr.  II.  .M.  'riiomas  in  Volume  II.  of  the  /.V/w;tf  (18'J0).  I  give 
here  a  brief  abstract  and  a  note  of  his  condition  subsequently  to  Dr. 
Thomas's  report  : 

('ask  I.  For  xi.r  ((>//( /c/N  attach  nf  Rai/naud's  disecme ;  attric/c--i  of  epi- 
l>'p<il  iircii, :  liKj  Dii/ji  ivhfii  the  /()''iif  ■■<!i)i}pti)in^  )vrr(' prr.toif  ;  hdiiinrffohimirla. 
— Tliis  man,  aged  twenty-six  years,  had  liad  for  three  winters  in  succes- 
sion attacks  of  Raynaud's  disease,  the  hands  and  feet  and  cars  and  nose 
being  affected.  The  case  ))rcsente(l  nothing  unusual  so  far  as  tlie  local 
coiutition  was  concerned.  He  had  had  losses  of  sul)stance  in  the  ear-tips, 
but  not  of  the  nose  or  of  the  fingers.  The  most  reinarka1)le  jjcculiarity 
was  the  occurrence  of  the  disease  in  the  winter  only,  and  the  association 
of  it  with  severe  cjiileptic  convulsions  and  with  ha'moglobinuria,  asyni])- 
toin  which  has  l)eeii  fre(piently  noted  in  the  disease.  The  epileptic 
attacks  occurred  only  in  the  winter,  and  always  in  association  with  the 
local  as])hyxia  and  the  bloody  urine.  The  report  given  by  Dr.  Thomas 
is  up  to  January  10,  1(S!)0.  The  patient  wius  in  the  wards  on  two  subse- 
(|uent  occasions:  on  February  (i,  1892,  and  March  21,  IHH.'i.  In  the 
winter  of  18ill-()2  the  ears  and  nose  troubled  him  very  much,  and  he 
had  had  blotches  on  the  arms.  Up  to  the  date  of  his  admission  he  had 
had  no  convulsions.  He  had  had  several  attacks  of  bloody  urine.  We 
did  not  see  him  again  until  March  21, 18n;>.  During  this  winter  he  had 
repeated  attacks  of  discoloration  of  tlie  ears,  iiose,  and  fingers,  with  the 
])assage  of  i)loody  urine.  On  this  admission  he  had  no  convulsions. 
He  had,  however,  two  additional  symptoms  of  great  interest,  namely, 
attacks  of  severe  abdominal  pain,  resembling  colic,  which  recurred  at 
intervals,  and  enlargement  of  the  spleen,  which  could  be  felt  4  cm.  below 
the  costal  margin.  The  patient  has  not  been  under  observation  for  the 
past  three  years,  and  I  have  not  been  able  to  find  his  address. 

I  can  find  no  parallel  case  in  which  the  epilei)sy  occurred  only  during 
the  manifestations  of  Raynaud's  disease. 

So  far  as  I  can  gather  from  the  literature,  the  only  instance  in  which 
a[)hasia  dcvelopeil  in  connection  with  the  iittacks  is  reported  by  M.  Weiss.' 

A  woman  of  very  nervous  tein})erainent  was  subject  to  most  aggra- 


1  Wiener  Klinik,  1S82. 


nrsRASR. 
inj;;e(I   local  clis- 

disturbances  iu 
ave  been  ejHlep- 

I  sliall  refer,  I 
be  directly  asso- 
n  C^ase  XIX.  of 
;ion,  the  woman 
specially  related 

lie  diseaf-e  by  a 
■eported  in  full 
^1890).  I  give 
ecjuently  to  Dr. 


;  attack-'^  of  ep'i- 
hd'innrffohiiinrla. 
inters  in  succes- 
d  ears  and  nose 

far  as  tlie  local 
e  in  the  ear-ti])s, 
al)le  peculiarity 
1  tlie  association 
binuria,  a  symp- 
The  epilejitie 
ciation  with  tlie 

by  Dr.  Thomas 
Is  on  two  subse- 
,  189.'].  Jn  the 
y  much,  and  he 
dinission  be  had 
ody  urine.  We 
is  winter  he  had 
fini^ers,  with  the 
no  convulsions, 
iiterest,  namely, 
ich  recurred  at 
felt  4  cm.  below 
ervation  for  the 
dress. 

red  only  during 

stance  in  which 
id  by  ^l.  Weiss.' 
to  most  aggra- 


osi.i:!} 


f'f>MlM,|(.,\  p 


vated  attacks  „f  ] 


'<..VS    OF     ,{.\v 


\.\ri 


'    '^     l>l-^KAsi; 


superfi 


oc;d  11- 


eial  gai 


half  of  the  f 


gangrene  of  d. 


l'''r-^i'i  in  til,,  (i 


Hirer." 


Icll 


cheek,  f, 


buttock- 
I)aiior, 

IW(>Ut\-  I 


On  Octol 
and   sli.rl,, 


"'-"  'I'ld  patches 


'  '"'l(.u,.,|  hv  .,, 


"■itii   ai-tlin,j 


lillllic 


'<'i''^lh  sli,.  I 


.f 


cN-aiiDsi,. 


'iiinuic 


i>ttril)uted   rl 


On   X 


lad 
"f  the 


•'upei'lici 


i''ciil\-  distiirl 


'■"I'liy  «(  llic   l,.f| 
gangiHMiM  (Ml    tlic 


lips 


T 


laiicc  of 


the  third  left 
III    the   foil 


'c  cerei)ri 


"^■'■"''"■''  "'tl.   siie  iia.l 


'"■   i'ltack    ia-ied 


l"'ccli,  will. 


lift 


ani 


frontai 
lowinir 


■^ynipioiiK  I 


1''"'^'"  "iih  transient  I 


'■"iivolniinn 
i'''inarkai)|i 


'  a  spast 


'•^  -iniiiar  attack.     \\ 


cell    or 


ic  iscii 


ei.> 


:<'inni  in  tiii.  i 


'"ise  til 


iciini 


'Icyia, 


'11 


ere   ^\■^,y^,   ,.,.,. ^ 


rriiii 


( 

off/, 


AS 


nioff /,,>;/  nf.th,.  fi 


''  ''linieal  sn 


■cgloii  of 


attack^  of 


miiiarv  is  as 


ollow,- 


"/■  -"/.r 


h 


"/'•-•.  ii'iii,.'<;,.„f ' I, 


IIIJl  r: 


■'''''!!'■''  '"'''iixi'tnni  ott„rL 


l>'ttii  iiiul  l„,,„l 


'  III   ( 


III  II. 


•ItllxOUlllsiu 


AprH^  IS!)] 


""   'llf'irl.-   of  ,/;■. 


I'l    mini  In 


"""•m,,  m.j,  „  tl;,,, 


'i'y:"''>'>tiii;ff/r  0,1,1 


"  iiioiifh  lilt, 


mid. 


■-"iperfirifi/ ), 


'icon, I  ott,,,./- 


'•''ro.yi.u,ff/„.f. 


iittor 


ii'Ifh 
wHI, 


•/•;'://;xr:^i:r';-^'-f^--'>/^'w:r. 


rifjhf  lionil.      .1  ,;;,;,,^/^ 


I'm !  nil  I  ,1  In,/, 


'"'"■h-  on  tl, 


iiiii 


■yipiini,;/  „.;//;  „,,.,/^ 
''■l';''.!''"-''"l''->-<n„llit'l, 


yilii/.riii  on, I 


On  .Uorrli  .1/sf 


'II',  mill  irl/li 


'il  of  /■)./, 


'■Jiiiij 


mil. 


''■"Ill/  nttorl- 


'"'"!  '""Ifli  nnfil  fh 


l""-''f^<>(th,-n,,hf„„t 


"■'","•.'/.  ','■'■///  ,ipho::;o.  I, 


.  ■    ■"  '•nil    I, nil 

"'III  ,i,'/„nr,  n,  til,.  ,,  1^,  f 


h,'  SI, 


"J  i-oinplilr  n„l. 


ll(T,-Osi't  of  / 


4f/i 
f'V, 


■rnilni,/  ,ii,„i, 


V  mill  fi, 


'iiiin,'! 


'pliii'<ni,  irlUi 


'fi-s  of 
'>/ 


f'^:'j^"''""^iii'ini:i:i 


^rm-e  „ff„,.l.^  ,,;,i^  1^ 


'in.r 


.WVV'/V 


/on 1 1 


lliiipfoni.s 
y>li,,sii,^  irlll 


IliinI  of  fuck  „f  ,^. 

''»  riiijif  1,11  i,;i  niHl'nn',;,, 

'"'/'lil/il  ,l,-i;'/„p-      ■      ■' 


■I'lhlrh 
■  III    fli 


'II 1 1 

'"'  mil 


In   h'ri 
fillip 


llllr 

'I  ■•'/I'jhf 


'irinii 


"/  i-'ulif  lion, I. 


I'i'I'liI  l-ri-i,ri'v, 

'/"/■■"'I  !'[_  fill'  ,;'f//if 

I'll  III 

'pfiil.riii. 


''jlit 
■II.  /,S'/y,7,  I,,,.,,/  ,       , 


III'  rii 


H 


aire( 


1   fort 
'••^i'itai.  Fell', 


'"'.7  ,'/'""/ 
y-cigiit  v' 


///./, 


','//'/  'l. 


Ifllf 


''l'.l"t  poivhlsi.  of  fl„.  i„t 
/lonil  oiii    h- ■       ,,    ■'. 


On  A,,,-! I 


ol  fi 


'iniiip/.,,;,,.  /,;,.„/ 


nipr: 


"iii'inp  /,S!)i!j„t 


•^ijni-op 


'■'''"'   i.i-finilln,)  to  fh 


On  .liilij  lutl, 
il  ii^iihit.i 


,1 


'II'  I'l  ho  II 


of   peeni 


uarv  !l. 


of  1 
liad 


Tlie  f 


nir  sensati 


■-;,ud,nittedto\va,;,  7. ;/;;;;;' 

.''V-.  eompiaininL^  of  ,1;.+;,.,,.,     • 


'"'"ly  liistorv 


ons  Ml  iier  W 


nijer.. 


'f  diftieiilt, 


'•>'■■«■  1"""  In  rlijhf  hun.l 

:  iliiifli,^-\{y^ 
■biinis  IIopl^ 


I'oino 


K'f  relative; 


Si 


IS  good.     .-^Iie  |, 


m   speal. 


Kill!. 


kin,- 
and 


one   iniscarriaire 
'lealtli.     In  1,S7.-,  sj,,.  | 


le  IS  ma 


rnei 
in    l,s7,s 


aiK 
A- 


':''""'^.'»fllnsi,nil 


as  ha 


a   rnli 


'I  a  mini 


"'  '•i>inp!aint 


icr  of 


III  anv 


iins 


and  i 
"six  week 
joint; 


Tl 


'le  attack 


"■'•'  '"•lite  rlienmati.. 


lie 


.\t 


.       ,  ""ix  Week.. 

Ill  tlie  big  toe.     O, 
colic,  and 


intervals 


wa-:  vi 


'I'y  intense  t 


■in.affeet 


has  eni 


ctiilijren.     S| 


le 


'•'   'lad  had  slio| 


'>ra  week 


ing 
and 


the  hand 


e.\cell,.i,f, 


W'^iiHiad  what   her~d 


It  I'etiiriis  of  tl. 
"x'tor  called    r| 


'•■*ted  ill  all  al 


ws. 


llHMlt 


le 


pains  in  tl 


she  doe; 


fill' 
oii'tl 


)r  fi 


roi'l  li\  her  |>hysieians  tl 


■'"f  fl'iiik  that  she  has 


lenniatie 
If  attacks  of 


:ors. 


\'('  or  six   year.- 


at 


!is  (>vei 
least 


passed 


a  stone 


'lal  slu 


lias : 


le 
.ii'ont 
I'eiial 
rravel. 


t  sense  of  thigiin.  and  nnml 


'<!  pads;  .sonieti 


nie.' 


the  fingers  lie 


"'<'S  t'>i>,  in  (he  i,.,|| 


I, 


chie 


'<'oiiie  mottled.     Tl 


I  .1  tew  hours,  thondi  slu-  | 

W<'eks.    The  tingiing  feel 


"I  the  t 


l-iecnliar  feelii 
■y  at  the  (i 


iiger-tii 


It'  condition 


lunil). 


At  I 


111  the 
and 


had  attac 


.["''•■jisted   iisnallv  f 


put  her  hand 


(111  ice. 


<ioiis 


T! 


iiig  was  sonietii 


'"  "''ii''Ii  it  lasted  t 


lese  tunes 
or  onlv 


le  I 


nc; 


fiiig 


she  hail  irregular  lilnisl 


III 


g"!'s  Wen 


'"i.iigi'a  vated  that  s| 


"I'oiie  or  t\\ 


o 


'',  'K'ver  l.lne,  but 


rers  novel 


>ecani(> 


that  of  chilblains,  tlu.u"l 


':{-;-.itheback..;heri:ht. 


en  .-several 


le  would 


ocea- 


aiK 


<iea( 


Tl 


K'  condition  rati 


land 


Tl 


'""'   iii'ver  suffereil   f 


ler  re; 


'iiib 


le 


''"'"  t'liit  complaint 


osI.IMJ:     com  I'l-tCATIOXS    of    UAVNAnD   .S    nrSEASK. 


'Ill 


US  ii  i:irl.  During'  tlicso  years  slic  never  tlioiiifht  seriously  of  tlie  comli- 
tioii.  It  wiis  ilnlll)yill,^^  I)iit  not  very  troiiltlesonie.  Tliu  toe.s  were  never 
iiffectcd. 

In  April,  1^!)],  slie  was  seized  with  di/./iness  while  at  tlie  lireakt'ast- 
tahle ;  a  ((iieer  sensation  iiepiii  in  tlie  feet,  si)rea(l  ail  over  her,  and  for 
a  moment  she  lost  her  siuht,  and,  she  thiidvs,  eouseioMsness.  The  attacks, 
thoiiirh  of  very  short  duration,  fri<,ditened  her  very  inueh.  A  month  later 
slie  hud  a  second  attack.  About  seven  o'clock  in  the  niorninL;  she  felt 
suddeidy  that  things  were  niovin;,^  and  slie  had  to  take  liold  of  a  chair 
to  ]ircvent  lierselt'  from  I'allin;^'.  She  was  jj-iven  liraiuly,  which  nause- 
ated her,  and  she  vonutcd  three  or  four  times.  The  tiice  and  li|)s  were 
conjrested,  not  pale;  the  s[)eech  was  in)t  affected.  Within  a  few  hours 
she  felt  (piite  well.  She  notii'cd,  lio\V(>ver,  that  iter  ri;;]it  arm  ached  veiy 
much,  iind  at  eleven  o'clock  she  looked  at  her  riu-ht  hand  and  saw  that 
the  little  and  I'iiiii' iinu'crs  were  ol' a  purplish-liinc  color.  They  remained 
lilack  and  painful  for  nearly  live  (lays,  and  were  nundi  for  a  loiijicr  time. 
There  was  no  loss  of  suhstam'c.  She  had  no  furtlutr  attacks  imtil  just 
five  weeks  a<ro,  when  she  aj;iiin  l)ecame  very  di/./y,  and  would  have  fallen 
had  .she  not  j^rasped  a  chair.  In  this  attack  the  index  and  little  lintrors 
of  the  riirht  hiind  were  affected,  and  the  iloctor  thouudit  she  would  have 
lost  them  l)oth,  as  they  remained  cold  ami  Mack  i'or  days.  The  skin 
turned  of  a  ii'reenish-hlack  color  and  u'radually  came  off.  The  nail,  how- 
ever, did  not  come  off.  The  linji'crs  mv  now  liealiuji',  and  new  skin  is 
forniiiif.'.  In  the  fir.st  attack  she  had  ,slij>ht  di.sability  of  the  liaial,  which 
ill  the  second  iittaek  was  much  more  marked,  so  that  she  could  not  dress 
herself  or  use  the  hand  to  feed  herself.  Shi'  thinks,  too,  that  the  hand 
was  somewhat  swollen. 

A  week  ago  she  had  a  tliird  attack,  which  came  on  witii  much  riiifxing 
in  the  head,  particularly  in  the  rij^ht  ear.  She  felt  very  dizzy,  hut  did 
not  lose  consciousness.  Her  teeth,  however,  chattered,  and  there  were 
involuntary  inoveineiits  in  her  riirht  hand.  She  had  headache  and  saw 
double.  She  found  that  her  riudit  hand  was  almost  useless.  She  could 
imn'e  it  from  the  elbow  and  shoulder,  but  slu;  could  not  hold  a  ,:ilass  of 
water.  On  atiemptiuL;'  to  jret  iq)  she  scarcely  could  stand,  and  the  right 
foot  and  leg  were  weak.  For  the  first  time  the  speech  was  affectiid.  She 
could  only  mumble  words,  and  could  not  be  understood.  She  had  no 
nausea  and  no  vomiting.  The  diftienlty  in  speaking  and  the  slight 
hemiplcLiia  have  persisted,  and  it  is  for  this  condition  that  she  seeks 
relief. 

S.  P. — T'lie  patient  is  a  well-nourished,  somewhat  corpulent  woman  ; 
the  color  of  the  face  is  good  ;  the  venules  (m  cheeks  and  nose  arc  a  little 
dilated.  The  pu|)ils  are  eipial,  react  to  light  iind  on  accommodation. 
There  is  no  diplojiia  ;  the  ocular  movements  are  perfect.  There  is  no 
facial  paralysis,  and  th(>re  are  no  disturljanees  of  the  seiis(>  of  taste  or 
smell.  The  temperature  is  normal ;  pulse  regular,  tension  a  little  in- 
creased ;  the  vessel-wall  of  the  radiid  arteries  is  a  little  sclerotic.  The 
iiKjvements  in  the  right  hand  are  good,  but  the  hand  is  weak  and  the 
grasp  feelile.  She  can  pick  up  a  pin,  can  use  a  fork,  and  can  write, 
though  slowly  and  with  dithculty.  She  says  that  the  power  in  the  hand 
has  been  returning  rapidly  within  the  jiast  few  days.  The  skin  )f  the 
left  hand  ami  fingers  looks  (piitc^  mitural.  The  terminal  phalanx  of  the 
right  index  finger  is  of  a  deep  bluish-red  color,  iind  the  nail  is  deeply 
discolored.     On  the  pad  of  the  finger  the  skin  is  very  dry,  and  there  is 


I 


ISEASK. 

if  tln'  condi- 
s  were  iK'vcr 

IC    lll'Cllkfilst- 

licr,  anil  for 
Till' attacks, 
inoiitli  later 
lintr  slu>  tVlt 
<l  of  a  cliair 
ivliicli  iiaiis(!- 
11(1  lips  were 
a  few  hours 
1  ached  very 
lul  saw  that 
icy  remained 
loii;^('i'  time. 
ks  iimil  just 
I  iiave  fallen 
little  HnfTors 
would  have 
-.  The  skiu 
he  nail,  how- 
new  skin  is 
hand,  which 
\h\  not  dress 
Kit  the  hand 

uu'h  rin.2'in;^ 
z/.y,  but  did 
1  there  were 
die  and  saw 
She  could 
Id  a  -lass  of 
nd  the  rifzlit 
tfected.  She 
She  had  no 
d  the  slight 
at  she  seeks 

lent  W(nnan  ; 
e  are  a  little 
)nun()dation. 
Tlu're  is  no 
e  of  taste  or 
1  ii  little  in- 
erotic.  The 
eak  an<l  the 
d  can  write, 
in  the  hand 
'  skin  ,>f  the 
idanx  of  the 
ail  is  deeply 
and  there  is 


"'"■^^  '"■•   nAv.v.vrn's   ,.,s,,vs,..      5 


';'"^K:;f''^rmdshn'  ;;,"''■'•''"''•'••■  ulnar  side  of, IH.  Ph., 
;<"'  Thenu-ddieand  vL  n^l  ^"  T' l'^  "'-  l'''=''""-v  there  I  .'w 
"'",  'f""  'i"..vr  i>  covered';  -^i'''  '"''"•  ''"''^'  '*■'■'"'""'  pl  I  n,  ,  f 
^r''  '■"•  "-"'  i'  looks  as  ,|,,„         i^'"'i:"^.":'"-  'l-nnis.     Tl„.  Lut^',  ' 


articuhitioi 


:V^'-s«i..:;;r;l:,t.t:;r'-K "'""'■""' ' 


po-astnc  and 


"''t;  'i'-'-.n,y.Hna,a.  ' '""" '''  """"i.i.'d  i.v  iar.;.'n,;s:;.:';;.;;;; 

"'<■  urine  was  Ij-lit   v,.ll„„.  ■         ,  ■  -  1  "  .. 

!'!""   ='   faint   rin.o,  !,,{:„'':?:.:".;;"'"'••.  ^vith  a  spcc_ 

ast 


'oniyoniata. 

...•'.lih':'";;:;' :,;ri;:;;;:;;:[ ';;;;'';;  "'--y". ■.<  ,<..  .,„i,.  s,. „"'" 

'■;.'  I'"itmi„„.    T       -„  :      '!"  "I  -I'o  «|."l;c  will,  ,.|,,,,„„    ,     '  ri, 
■■''""•' "v„,vf,,„„    !;/,■„    '""■', I'"l.^ii"l  tl n-slci.; 

Throu,!,rh  the  kindiK-s.  ,,f  [),.   i-  ,  ,  ,,    ,  , 
4,  l.S!»-Mu.says:         '      "  l"".^'*  >> -Ulus  ease.    In  u  letter  dated  .\p 

a..a.?:r;;:d'nn;'s:m!r':.::;;;:;;\f'''^^^    '-^i-i^^i  she  i,ad  .„.„„er 

"'•  with  loss  of  sp,;.i   ('  Vr  I  ''1''  ";'^'  ''■""'•'•' "'  tiie  i    ; 

she  was  ta  k  n^  wi.l,  son.e  frie     s  w  ,e     H,       ■',  /'I''  ,   •^'   ""'<■'•  "'^•'"H 
l''"-<'-     Tlu.re   was  no  iriddt:    '^,:^'':."'' ';'':"'>■ '''■-''"'■ '■'•nmlete]; 


at 
•d  .\j)ril 


>H'.-.^.     She  was  laid' 


messcnn-,,.  „,,,s  sent  to  fetd,  ,„,       f  ,.;     i  T,  '"','  ""  '•   '""'nire  and  a 
was  perfeetiv  .sensible    .  n   ,  •  V,      ■      ""'"'''  ^''*'  '"^"^''  ^t  4  .m,      4e 

-pb-  ^1.0 -could  ;;t;S"r;;^.rsnr^' ,'''■•  "-^'^  "''''■''-» 

H.o  seemed  to  know  what  sh..  w ZC    ,         ■    i""'    "1'^'"  f'""    '"""th. 

f-      Hu.re  was  no  donble  visln       'n';'  Ti''.       /''''"'''  ""'  ^•^'•"•"•^•^ 

times  convulsed.     The  •itto,  ,  •  ■>       "-'"   '"""'    "as  stiff  and   .u 

^^  wc  1  as  before  the  attack.     T  c  l  uC'     '^"'  ^'"^ '"'^^  ''"^  ^''^  tallied 


any  thrcatenino'  of 


e  on  lio 


'li  hands,  not 


lere  woiv  one  or  t 


:an,!j'i'ene  as  was  f 


associateil  will 


wo  snndl  discolored 


"rinerlv  tla 


'  any  paui,  or  with 


•ase  in  the  fini'-ers. 


H    1! 


I? 


6       ()SI,KK:     com  IM,l("A'l't(>NS    OK     KA  Y  N  A  I"  d's     DISKASK. 

Dr.  lioiitclU;  int'oniis  iiic  tliiit  fniiii  this  ihilc  until  the  siniinicr  of 
IM'.M  slic  iviimi!i(>(l  well,  Imviiij,'  no  syniptdiiis  of  the  trDiiitlc.  Al  this 
tiiiic  sill-  liiid  a  sudden  iittiiek  of  pain  and  aehintr  in  the  rijjht  lejj  and 
toes,  imt  no  discoloriition.  The  pains  would  last  for  from  a  few  niinnten 
to  a  few  hours  and  then  disiip[)ear.  I'nder  ilatt'  of  March  2."),  j.S!)."),  he 
writes : 

"  Hix  weeks  aj;o  the  middle  finj^er  of  the  ri,i;iit  hand  lieeame  very 
dark  over  the  termimd  phalanx,  just  as  in  the  old  attacks,  i)ut  there 
Were  no  ccrehral  symptoms.  Tlie  discoloration  has  hccn  disappearini,', 
and  is  now  almost  ^one.  Tlie  nail  is  slightly  raised,  hut  I  do  not  tliiidv 
it  will  come  off.  She  con^nitiMl  nie  lately  for  a  return  of  the  interndt- 
tent  pains  in  the  riuht  ley'.  (Thesi'  are  prol)al)ly  pres<ure-pains  from 
the  myonuita.)  The  i,'eneral  a|)peanince  is  healthy,  the  pni)ils  are  nor- 
mal, and  the  s[)eech  is  natural.  She  took  at  this  time  nitroj^dycerin  in 
very  full  doses  with  >ut  any  l»(>netit," 

On  .\i)ril  «,  iMil.-),  Dr.  Moutelle  writes: 

"  Just  now  Mrs.  — 's  case  is  presenting;  some  very  peculiar  features. 
On  .\pril  4th,  ahout  !)  I'.M.,  she  had  an  alta<'k  ot  t'aintness  and  jiiddi- 
ness,  witii  pain  in  the  index,  rinjr,  and  little  linger-  of  the  ri^ht  hand. 
I  saw  iier  the  next  evenin;^- ahout  idx  o'clock.  She  had  had  a  severe 
headaciie,  partirularly  in  the  riji'ht  temple.  She  said  that  her  left 
arm  and  ley  felt  weak  and  heavy,  hut  she  couhl  move  them  very 
well.  There  was,  howevi'r,  nnirked  clumsiness  of  movement  in  the 
left  hand.  The  tinu'crs  were  sendllexe(|,  and  she  had  dithcnlty  in 
straiu'hteninii'  them.  There  was  m)  <iiscol(U'ation  in  tlu'  left  liand.  Tlu; 
termimd  |)halani;('s  of  tiie  index,  riui:-,  and  little  tinucrs  of  the  riyht 
hand  wei'c  <liscolorcd  and  tender  to  tlnUouidi.  ( )n  the  palmar  aspect  of 
tile  nuddlc  phalanx  of  the  index  flnji'cr  and  on  the  palmar  aspect  of  the 
metacarpo-phalanireal  joints  of  all  the  linj;-crs  of  the  riuht  hand  there 
were  spots  of  discoloration,  sii<,ditly  tendi'r.  The  following  day  the  di.-<- 
coloration  of  tlie  riuht  hand  was  less  marked.  The  speech  and  intelli- 
gence were  mumal.  The  slight  paralysis  of  the  left  hand  continues. 
She  moves  it  with  difficulty.  To-day,  the  .Sth,  the  discoloration  is  more 
marked  in  the  lingers,  which  are  very  tender." 

This  patient's  son,  a  young  nn.'dical  man,  has  kindly  sent  me  the  fol- 
lowing note  of  an  attack  which  occurred  on  .Inly  l!),  1.s!).5  : 

Wh.le  dressing  the  patient  had  an  attack  of  jiartial  unconsciousness. 
For  ten  minutes  the  right  side  was  helpless  and  the  speech  impossihie  ; 
siie  was  dull  and  very  lethargic.  The  arm  recovered  motion  lirst,  and 
then  the  leg.  Sensation  was  restored  later  than  motion.  She  com- 
plained of  a  dull,  aching  feeling  in  the  arm  during  the  day.  The  hand 
was  stiff  and  the  mi<ldle  finger  hlue.  On  the  20th  there  was  still  aching 
in  the  right  arm,  with  now  and  then  an  cxacerhation,  until  luncheon, 
at  n(jon,  at  which  time  all  the  fingers  and  the  hand  hecanu;  of  a  dead- 
white  color.  Jn  a  short  time  the  tips  of  the  fingers  itecanic  dark  hlue, 
and  spots  of  the  same  color  appt^ared  on  the  hainl,  j)articularly  in  the 
palm.  The  pain  was  very  intense,  and  she  suffered  terribly,  re(|uiring 
several  hypodermatic  injections  of  morphine  in  rapid  succession. 

On  July  21st  the  hand  was  (k'ad  white,  cool  ;  the  terminal  i)halanges 


I  s  I-;  A  s  K. 

siiinnicr  uf 
Ic.  At  this 
rill  III:  iiiid 
few  iniiiiilfs 
17),  l«!l.->,  lie 


I'caiiii'  very 
s,  hilt  tliiTo 
isll|)|)(■n^iIl^^ 
lo  not  tliiiik 
ic  iiitci'iiiit- 
-paiiis  from 
)ils  arc  nor- 
iitrlvc'crin  in 


iar  features. 

ami  i_i'i<l(li- 
riiilit  hand, 
ail  a  severe 
lat    her  left 

them  very 
iieiit  ill  the 
liliiciilty  ill 
liaiiil.  Tlu; 
)f  the  ri;;ht 
ar  aspect  of 
ispeet  of  the 

hand  there 
day  the  dis- 

aiid  intt'lli- 
1  (•ontimies. 
tioii  is  more 

1110  the  fol- 


mscioiisiiess. 

iiupossihie  ; 

111  first,  and 
She  eom- 
Tiie  hand 

still  aehing 

1  Inneheoii, 

3  of  a  dead- 
dark   blue, 

larly  in  the 

y,  re(|uiring 

sion. 

[\  phalanj,a's 


(>«Li:i{;     « 


OMlM,/(   A,., 


<  t  \  s 


"I'  i;av 


lihle,  \vi( 


.V.\  11) 


I  a  feu 


•^    l>ls|.; 


"".i.1;f^;,:>t;- •'":,::-,. 


^eatlen 

II'.  tl 


A  s  I.; 


'■-pOl.v    oil     (I 


".''."•"I-     Tl„.  tipuf  ,1 


Ti.:  :::::::'"":"'.»'-•'-'- iud 


pn  )(■(■; 


il  spot   of    ,.,.,.] 


""'"••I'/VomtJM.stvloid 

<'n  the  L'-'d  sli(.\vi  ■■'-■■•  ' 

i'andvvasstil|,.o|,|    ,';■;;;;''>•','''''■''!''•'''•'•.  and 


'f  tl 


"'  •U-'lit  radiii 


iiyiiiosis  iiii  i 


<"iy  sviiipiiiii 


le  nose 


lie 


On  ti 


<'xaiMiiied  hci 


I  and 


atropii 
On   April 


eves. 


In  Ihi 


and 


'lile  (•()!,, 


'r  of   (lie  (i 


';:;;."i!rr'-i'i'"y.  At^H 


"a-i  ;il)||.  (,,  ^.,.| 

'".vers  was  fad 


nil. 


i.v  half 
The 


in. 


iltlaek  (I 


'!'■ '-'  ••'-.•oi;Htis:  ui  ril";!!' "."  •"•-''■^^ 


I''  nriiic  u 


.^r 


rs. 


lied  ,1 


'■^"".  l>r.    l!o,„..|| 


ii>  iienativi 


I   oiuiiini 


111:  optic 


<•  uritcs: 


'".V  'ast  report.      | 
wvere  thoiiol 


Hillary  :.'!)    l.s; 


last  ,si 


I  as  (h,.  f 


.""""■'•  -lie  had 


":•     She  did 


oriiic 


a  rati 


vcrv  Well  f 


'•'■  a  time  at 


s.i'!;::;;;;.,';"""' i.  .;;;i™r-;r'."' -- 

<liiy  took  a  d 


"•'■  |'i'olon;r,.,|  attack 


ler 


eerate 


Karl 


V  III    ,1 


l'"i"  in   the  (i 


"i.v  rooK  a  (  r  ve  ■m.l  ..l         •  •■■■"'•■y,  a 
'liohadan..,!.  .1    '.".";..'•'""■'•  I'"artil 


Hillary,  after  f, 


",ii<'i'S  whiel 


vsis  or 


liiii. 


|>aral 

'  f II rued   livid"  i 


."'  attack  of  ui.i.i 
"■   'yl'l    hand.      M 


in   tl 

l"iiii,  which  si 


I II  ess 


y  at  sii 


pretty  well,  si 


not  so 
iraiii- 


lilt 


l'l'<i'.      Dii 


le  one 


'-•'/-■''i'in.,Wi:;ved'h::';;.^l:!,'''^!'' 


;;i'l7"rm.    All  of  the  ,i 


.";  '■"I'l'l  not  locat, 


'I'll had  to  I 


.V  intense 


'I'  ^iv.Mi   fivlv  to  rel 


pain 


the  liand.    Slu 
wisnolossofpo«;,".t 


tl 


,.  "V'l's  liirncd  1 
>™.- a  htt'e  l,cwildere,| 


•^actly,  ivf'erri 


'liie,  and  tl 


"^'  H   to  the  cll 


K'Ve  the 


10  most  ill! 


eiise 


.-peccli.    \ 


and  eoiifi,.,,,,! 


lore  was  i 


'"  ■■'oiisatioi 


low  or 


}i"til  Ihv  hand  and 


pain,     (iradii 


'•.V">"vei,iciitofi|,c|,an;i 


mentally,  |„|(  t| 


I  111 
lore 


allv  tl 


lie  eold 


into  a  ei 


'Ilia,  an 


ir 


7;li;;;'L'!;-,:':';-^r;-:;'i:; 


and 


livid 


"■''  '"  a  eoiiplc  of  ,1 


'■•••^o'l  writes  ahont  the  final 


IM'S 


ir  as  the  cll 


'"'  arm  pive 
".V  iiK'i'oased 


low.     .'si 


le  said 


'On  \ 


'land  and  finy 


ii"'  I'otuni  I 


attack 


"""••  at  his  mot  I 


to  the  shoulder,  and 


'•'■•■■*  eoiiiplctcl 


■an,ureii()iis 


'ci'V  final  ill 


lie: 


pino'roiions. 


as  (ar  as  the  cll 


Tl 


'le  found 


low  It 


*v.MV  and  persistent  hoadach 


''</"'".',"■""  mottled 
if  it  must  also  I 


tlie   rinht 


lool<cd  ,1 


nearly 
leooiiie 


plaoo  of  a  well-marked 
the  discussion  of  a  case 
coniplicated  the  d 
tor  vol 
I 


isease. 


attack,  has  I, 
I'oporteil  hy  ('] 


'ilteriiatiiii 


wit 


'  '"■  '■^■^"  fakin^r  ti,e 


■y  similar  to  that  whicl 


''lo  patient 


'I'll  retbrred  to  hy  If   c    \y 
'7"a".i/ in  which  angina  pe.:;;.; 


ooil  ill 


descril)(.d  the  j 


the  follow 


iiiii  indehted  to  Dr.  fj.  \ 


'  ncciirrod  in  the  fi 


po( 
'am  as  of  a  ,■! 


iiger.- 


larac 


•iiig  case 


pDssihlv  of  tl 


<Non,  of  Mih,.^„|,, 


CasioIII.      Painful. Mvell^ 


'<■  nature  of  \ 


vaynaiid's  dj 


'•'.  for  the  ivpoi-t  of 


reciirniiij  for  tw 


'(>  (tod 


po.is;/,nf  /,!/.sU.riral.~K   T 
neurotic  fiimily.    She  is  a"l 


fiu/f 


''"!/  of  the  A 


isoase 


//'■'"•■-•  ,■  f'llli 


y.i  hdtm-n  the  k 


'Hi'i;.' 


'»<!  iiiik/r. 


■i^^e.l  thirteon  and  a  half 


",'/  uHueh  of  <Jouhffal  >J 


t"  \vhat  appears  to  have  1 


ii'^^c,  hoalthv-lool, 


vears,  ( 


■''•'man,  of  a 


-ioventy  when  shew 


"'•ef.  ^'i-oups  of  sv...,,,, 
swelling  hchind  tliV  left 


as  ten 
ptoni 


'foil  an  attack  of'vl 


'".^,^■"•1.    Ilcr  illness  I 


loifan 


years  old.     Tl 


VIZ. 


lainful 


V^  was  followed 


'<"'oa  of  coiisiderahle 


tiiiuc 


welling  of  the  I 


iinniediatoly  hy 


'If  until 
1.   About 


now. 


a  V 


'-'''"'' <*'^«-^'-Miuys,^i:>::::'" 


ear  after  the  onset  the  cond 


lave  con- 


'  ITaiisactiotis  of  the  Collegi 


'tion  of  the  Jeg.s  is  de.. 
"f  I'liysicians,  Pliiiadelphia,  1S92. 


<eribed 


m 


8       O.SI.KIi:     COMIM-ICATIONS    OK     I!  A  Y  X  A  I' H 's    DISKAhk. 

Ity  II  |»liysici:iii  wliii  suw  her,  as  fulldws;  Tlir  child  was  ki'iil  lo  ImmI  ;  (Ik 


paiii  came  dii  aliuiit.  M  r.M.,  and   lasted  im 


th. 


Ic-.-  thn)ii;;li   till'  iii'dit 


fioiii  aiikli-  t(t  kiici' were  piirfv,  swolli'ii,  and  red,  cxlrcinch 


lul.and  vcrv  nnirkiMlly  liyiicra'stlu.tic."  She  lost  niiicli  slct'paml  i 
ni|)idly.     'Ihis  Mtate  liatrdcvcliipcd  rapidly  at'lfr  tlic  chor 


V  pain- 


an  down 


W 


ln'n  I  lirst  saw  lur  in  .Inly,  !««•"),  i|,(.*|,iiint'ul  attack  ca 


u'  on  Ml  the 


middle  of  tlie  inornin;;',  and  lasted  a  couple  ot'  lioiu's,  and  diirini;'  tli 
time  the  condition  was  much  the  same  as  descrilied  aliove,  thon;;h  niiicli 
less  severe.  !•.  ili(>  interval  the  skin  had  a  reddish,  mottled,  (e.lematoiis 
look.  Some  coiisiunt  |)tiiii  aiul  oxccssivc  hypura'slliesia.  As  well  as 
t'oiild  1)1'  made  out  the  sense  of  temperature  was  liiiinted,  if  not  lost. 
Knee-jerk  jircseiit,  lhoii;.di  sliirhi.  'rh,.  nffected  area  extended  from  the 
insertion  of  the  patellar  li;i;aiiieiit  to  ankle,  and  was  sharplv  delined  at 
each  limit,  and  extended  coiimletely  around  the  le;:s. 

I)rrniihr,\  1H,H.').  On  the  whole  better.  The  affected  area  lui«  lieeotuo 
limited,  liy  the  approach  of  the  upiier  and  lower  hoiindari. s  some  two 
or  tlireo  iiiehe.s  nearer  each  other,  lias  better  and  worse  days,  hut  for 
last  year  or  more  has  lieeii  active  in  playin;:  about,  except  duriiin-  attacks 
of  jiaiii,  and  lately  these  have  not  been  severe  or  distinct  eiioii;:h  to 
iiiake  her  lay  up,  but  all  day  the  condition  is  as  described  in  July,  IMS.'), 

cominj,' 


the  subjective  sense  of  [)aiii  \io\\\<x  off  when  she  jioes  to  bed,  but 
on  in  tJie  morninjr,  sometimes  before,  somotiines  after  Ki'ttiiiir  up 


2.  Ever  since  the  l)e<.nniiinir  has  had  a  deep-seated  earache,  more  or 


.s  constant.     This  is 


accoiiipaiue(l    liv  reiliies; 


lIKi 


<well 


iiiastoid   proce>-,    which  comes  and    e(„;s,    but  never   suppiir 
intensity  of  the  pain  and  swelliiit;-  coineid 


iiiii'  over  tile 


ate: 


Tl 


10 


1   Fallini,'  attacks.     At  lirst,  and  for  a  year,  she  would  fail  forward, 


two  or  three  times  a  dav,  on    her  hands  and  head,  and   mil 


would 


roll 


over  on 


the  1! 


ess  eauuht 


0(M'. 


Tl 


lere  was  no  aura,  no  ei 


probably  no  loss  of  conseioiisiiess,  but  of  this  she  is 


llivul: 


piick.    I'\)r  the  last  two  vears  has 


not  sure. 


'ion,  and 
{ecover\' 


was  ( 


or  ioiiii<''e,  never  1 


alwavs  had  tune  to  "ct  to  a  chair 


OSes  consciousness,  and  it  never 


lasts 


more  than  (ive 


niiiiutes,  and  often  only  a  few  seconds.     I  .saw  one  which  consisted  merely 
in  puttinjr  lier  head  on  iier  mother's  shoulder,  who  was  sittinjif  near  her, 
1   almost  iiumediately  pickiiiir  it  up  again.      It  had  the  apjuarance  of 


am 


being  done  Un-  my  lu'uelit.     During  these  attacks  she  feels  faint  and 
jiowerless.     Iloart-sounds  normal. 


nrHKAHK, 


|)l  li>  Ix'il  ;  the 
i;;li  llif  nielli  ; 
xti't'riit'lv  imiii- 
uikI  I'liii  ilowii 
ca. 

I'llinc  (III  ill  the 
hI  <liii'iii;:  this 
,  tlimi<r|i  iiiiicli 


ilciiiat 


llll^4 


.  As  wi'll  lis 
'il,  if  nut  lost. 
ihIi'iI  I'i'iiiii  the 
|>ly  (Itliiii'd  at 


t'U 


has  I 


•ec'diuo 


irit  s  some  two 
■  (lays,  lull  for 
liiriii;^-  atta<ks 
1(1  (•iioii;.''li  to 
ill  .Inly,  !«?<. 
(I,  1)111 


(•(iiuiiiir 


in;:  ii|i 

•aclic, 

iliiii:'  over  tlio 


iKii'c  or 


jiiratex. 


'i'l 


10 


fall  t'onvai'd, 
unless  (■au;jlit 
inviilsioii,  and 
[•e.  h'ccovcry 
got  to  a  chair 
lore  than  five 
isistcd  nu'ivly 
tiiij,^  near  her, 
ii|)|K'araii('c  of 
'ols  faint  and 


